Provider Demographics
NPI:1134891682
Name:PRENDERGAST, JACLYN MARIE (OTR/L)
Entity type:Individual
Prefix:MISS
First Name:JACLYN
Middle Name:MARIE
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:58 SUNSET TER
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:10930-2638
Mailing Address - Country:US
Mailing Address - Phone:845-774-6514
Mailing Address - Fax:
Practice Address - Street 1:1640 ASHLEY HALL RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-3824
Practice Address - Country:US
Practice Address - Phone:843-277-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6306225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist