Healthcare Provider Details

I. General information

NPI: 1619458817
Provider Name (Legal Business Name): JACKLYNN SYKORA PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2018
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3922 W RIVER DR
CORPUS CHRISTI TX
78410-5725
US

IV. Provider business mailing address

PO BOX 1214
ODEM TX
78370-1214
US

V. Phone/Fax

Practice location:
  • Phone: 361-767-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2090632
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: