Provider Demographics
NPI:1306495866
Name:TELLES, JACLYN SALCIDO
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:SALCIDO
Last Name:TELLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11704 HAMPTONBROOK DR
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75071-6119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3980 STATE SCHOOL RD
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-8823
Practice Address - Country:US
Practice Address - Phone:940-591-3646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-08
Last Update Date:2019-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211300224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant