Provider Demographics
NPI:1316255318
Name:BOVINO, JACLYN K (COTA/L)
Entity type:Individual
Prefix:MISS
First Name:JACLYN
Middle Name:K
Last Name:BOVINO
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 TRAVELERS BLVD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-3030
Mailing Address - Country:US
Mailing Address - Phone:843-638-3239
Mailing Address - Fax:
Practice Address - Street 1:950 TRAVELERS BLVD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-8287
Practice Address - Country:US
Practice Address - Phone:843-638-3239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001191224Z00000X
SC3692224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant