Provider Demographics
NPI:1902570542
Name:SCANLAN, JACLYN ROE
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:ROE
Last Name:SCANLAN
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 1:3947 QUINCY DR SW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-9818
Mailing Address - Country:US
Mailing Address - Phone:182-791-3753
Mailing Address - Fax:
Practice Address - Street 1:3190 E MERIDIAN PARK LOOP STE 206
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7422
Practice Address - Country:US
Practice Address - Phone:907-373-9462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist