Provider Demographics
NPI:1972885440
Name:GRAD, JACLYN (PHD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:GRAD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 280148
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32228-0148
Mailing Address - Country:US
Mailing Address - Phone:904-270-4338
Mailing Address - Fax:
Practice Address - Street 1:3851 ROGER BROOKE DR
Practice Address - Street 2:MCHEQD
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4501
Practice Address - Country:US
Practice Address - Phone:210-916-2460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001304103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist