Provider Demographics
NPI:1386219640
Name:ROMINES, JACLYN NICOLE
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:NICOLE
Last Name:ROMINES
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 1:2109 INDIGO WOOD CT
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-6399
Mailing Address - Country:US
Mailing Address - Phone:865-661-3638
Mailing Address - Fax:
Practice Address - Street 1:2109 INDIGO WOOD CT
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-6399
Practice Address - Country:US
Practice Address - Phone:865-661-3638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3936225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant