Provider Demographics
NPI:1306312228
Name:PETERMANN, JACLYN (OTR/L)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:PETERMANN
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 1:111 MONTCLAIRE CIR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:SC
Mailing Address - Zip Code:29657-5200
Mailing Address - Country:US
Mailing Address - Phone:862-812-3014
Mailing Address - Fax:
Practice Address - Street 1:208 JAMES ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29625-2942
Practice Address - Country:US
Practice Address - Phone:864-226-3427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4975225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist