Provider Demographics
NPI:1063759801
Name:TAMAYO, JACQUELINE MAY (OT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MAY
Last Name:TAMAYO
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:MAY
Other - Last Name:MCLAURIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:UNIT 33100
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180-3100
Mailing Address - Country:US
Mailing Address - Phone:314-590-4077
Mailing Address - Fax:
Practice Address - Street 1:UNIT 33100
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180-3100
Practice Address - Country:US
Practice Address - Phone:314-590-4077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8943225X00000X
CAOT17394225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ52237AMedicare PIN