Provider Demographics
NPI:1568297604
Name:TYRRELL, JACLYN LEE
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:LEE
Last Name:TYRRELL
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 1:220 OAKWAY CTR
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-5618
Mailing Address - Country:US
Mailing Address - Phone:541-334-5000
Mailing Address - Fax:541-344-5266
Practice Address - Street 1:220 OAKWAY CTR
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-5618
Practice Address - Country:US
Practice Address - Phone:541-334-5000
Practice Address - Fax:541-344-5266
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27657225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist