Provider Demographics
NPI:1578831020
Name:CHRISTOFFERSON, JACLYN
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:CHRISTOFFERSON
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 1:430 WILLOW RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-9239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:142 BERMUDA VILLAGE DR
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:NC
Practice Address - Zip Code:27006-7867
Practice Address - Country:US
Practice Address - Phone:336-940-3557
Practice Address - Fax:336-940-3557
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6893225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist