Provider Demographics
NPI:1548711229
Name:NYE, JACLYN M (BH)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:M
Last Name:NYE
Suffix:
Gender:F
Credentials:BH
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BH
Mailing Address - Street 1:1332 PLANTATION RD NE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-5713
Mailing Address - Country:US
Mailing Address - Phone:540-725-1572
Mailing Address - Fax:
Practice Address - Street 1:1332 PLANTATION RD NE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-5713
Practice Address - Country:US
Practice Address - Phone:540-725-1572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000853101Y00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor