Provider Demographics
NPI:1982371902
Name:THOMAS, JAQULYN DIANNE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JAQULYN
Middle Name:DIANNE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JAQULYN
Other - Middle Name:D
Other - Last Name:HUGHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:PIPER CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60959-7095
Mailing Address - Country:US
Mailing Address - Phone:815-686-2277
Mailing Address - Fax:815-686-2560
Practice Address - Street 1:600 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:PIPER CITY
Practice Address - State:IL
Practice Address - Zip Code:60959-7095
Practice Address - Country:US
Practice Address - Phone:815-686-2277
Practice Address - Fax:815-686-2560
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.009338225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant