Provider Demographics
NPI:1891931226
Name:HARRISON, JACLYN MICHELLE (DPT)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:MICHELLE
Last Name:HARRISON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22001 SUSAN LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-8305
Mailing Address - Country:US
Mailing Address - Phone:714-864-7089
Mailing Address - Fax:
Practice Address - Street 1:13001 SEAL BEACH BLVD
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-2753
Practice Address - Country:US
Practice Address - Phone:949-340-6927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-07
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT35189225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist