Provider Demographics
NPI:1053296673
Name:FANTOM, JACLYN
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:FANTOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2734 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-4902
Mailing Address - Country:US
Mailing Address - Phone:267-684-9027
Mailing Address - Fax:
Practice Address - Street 1:2410 S BROAD ST STE 101
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4418
Practice Address - Country:US
Practice Address - Phone:215-334-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-11
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT033564225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist