Provider Demographics
NPI:1912394669
Name:PLANZ, JACLYN
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:PLANZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:SAMUELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:75149 BROOKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-1620
Mailing Address - Country:US
Mailing Address - Phone:904-923-1781
Mailing Address - Fax:
Practice Address - Street 1:12276 SAN JOSE BLVD STE 508
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8618
Practice Address - Country:US
Practice Address - Phone:904-886-3228
Practice Address - Fax:904-485-8876
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician