Provider Demographics
NPI:1316341050
Name:WEBBER, JACLYN PHIPPS (OCCUPATIONAL THERAPI)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:PHIPPS
Last Name:WEBBER
Suffix:
Gender:F
Credentials:OCCUPATIONAL THERAPI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 168
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39059-0168
Mailing Address - Country:US
Mailing Address - Phone:803-929-7408
Mailing Address - Fax:850-588-9641
Practice Address - Street 1:4015 2ND AVE STE B
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-7882
Practice Address - Country:US
Practice Address - Phone:803-929-7408
Practice Address - Fax:888-711-0441
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT16627225X00000X
SC4394225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013553100Medicaid