Provider Demographics
NPI:1952974222
Name:DECARLO, JACQUELINE L (OTR/L)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:L
Last Name:DECARLO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 30TH LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81006-9524
Mailing Address - Country:US
Mailing Address - Phone:719-671-2251
Mailing Address - Fax:
Practice Address - Street 1:1015 30TH LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81006-9524
Practice Address - Country:US
Practice Address - Phone:719-671-2251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0000843225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist