Provider Demographics
NPI:1710790571
Name:HERON, JACLYN MICHELLE (DPT)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:MICHELLE
Last Name:HERON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2706 28TH ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1222
Mailing Address - Country:US
Mailing Address - Phone:303-444-1290
Mailing Address - Fax:303-444-1837
Practice Address - Street 1:2706 28TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1222
Practice Address - Country:US
Practice Address - Phone:303-444-1290
Practice Address - Fax:303-444-1837
Is Sole Proprietor?:No
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20362225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist