Provider Demographics
NPI:1386485035
Name:MOUNIE, JACLYN GRACE (PT)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:GRACE
Last Name:MOUNIE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 BURRUS RD
Mailing Address - Street 2:
Mailing Address - City:WANCHESE
Mailing Address - State:NC
Mailing Address - Zip Code:27981-9406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5585 N CROATAN HWY
Practice Address - Street 2:
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949-3996
Practice Address - Country:US
Practice Address - Phone:252-261-1556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP23271225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist