Provider Demographics
NPI:1801260492
Name:ROEPCKE, JACLYN (MS OTRL)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:ROEPCKE
Suffix:
Gender:F
Credentials:MS OTRL
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:MAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6987 SCOTT LAKE TRL NE
Mailing Address - Street 2:
Mailing Address - City:COMSTOCK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:49321-9603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2814 WOODCLIFF CIR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506
Practice Address - Country:US
Practice Address - Phone:855-583-2672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI5201009265225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician