Provider Demographics
NPI:1174991137
Name:CROOK, JACLYN NICOLE (OTR/L)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:NICOLE
Last Name:CROOK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 100TH ST
Mailing Address - Street 2:APT 2
Mailing Address - City:FORT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-1389
Mailing Address - Country:US
Mailing Address - Phone:312-371-6875
Mailing Address - Fax:
Practice Address - Street 1:1327 KALAKAKET ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4917
Practice Address - Country:US
Practice Address - Phone:907-452-4517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK102746225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist