Basic Information
| Provider Information | |||||||||
| NPI: | 1588143267 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARBONE | ||||||||
| FirstName: | JACLYN | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 BISHOP CT | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949453401 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 MONROE ST | ||||||||
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| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949542328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077634109 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2018 | ||||||||
| LastUpdateDate: | 08/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT12787 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.