Provider Demographics
NPI:1285937656
Name:DAVIS, JACLYN (LMT)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 N CHESTNUT ST
Mailing Address - Street 2:PO BOX 61
Mailing Address - City:ASSUMPTION
Mailing Address - State:IL
Mailing Address - Zip Code:62510-1003
Mailing Address - Country:US
Mailing Address - Phone:217-226-3335
Mailing Address - Fax:
Practice Address - Street 1:127 N CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ASSUMPTION
Practice Address - State:IL
Practice Address - Zip Code:62510-1003
Practice Address - Country:US
Practice Address - Phone:217-226-3335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.001409225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist