Provider Demographics
NPI:1962955518
Name:NASH, JACLYN
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:NASH
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 1:234 S FIGUEROA ST
Mailing Address - Street 2:APT 938
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-2541
Mailing Address - Country:US
Mailing Address - Phone:559-903-4864
Mailing Address - Fax:
Practice Address - Street 1:4515 OCEAN VIEW BLVD STE 320
Practice Address - Street 2:
Practice Address - City:LA CANADA FLINTRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91011-1438
Practice Address - Country:US
Practice Address - Phone:818-369-7620
Practice Address - Fax:818-369-7621
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2916562251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic