Healthcare Provider Details

I. General information

NPI: 1972248128
Provider Name (Legal Business Name): JACLYN MARIE NICODEMO LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACLYN MARIE NICODEMO JACLYN TASSONI

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 PULASKI DR
KING OF PRUSSIA PA
19406-2802
US

IV. Provider business mailing address

343 ROSS RD
KING OF PRUSSIA PA
19406-2108
US

V. Phone/Fax

Practice location:
  • Phone: 610-640-9355
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC009420
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: