Provider Demographics
NPI:1104578814
Name:STOLLFUS, JACLYNN (MOTR)
Entity type:Individual
Prefix:
First Name:JACLYNN
Middle Name:
Last Name:STOLLFUS
Suffix:
Gender:F
Credentials:MOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 KODIAK CIR
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-6080
Mailing Address - Country:US
Mailing Address - Phone:920-217-2007
Mailing Address - Fax:
Practice Address - Street 1:2600 PARKVIEW LN
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-7989
Practice Address - Country:US
Practice Address - Phone:817-857-4302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114071225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist