MEDICARE: JACLYNNE DANIELLE VAN OOTEGHEM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	120563	TX

General Provider Information

NPI Number	:	1770441552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYNNE DANIELLE VAN OOTEGHEM

Provider Business Mailing Address
First Line	:	3223 LEMMON AVE APT 2126
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75204-1817
Country	:	US
Telephone Number	:	972-251-0487
Fax Number	:

Provider Business Practice Location Address
First Line	:	3223 LEMMON AVE APT 2126
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75204-1817
Country	:	US
Telephone Number	:	972-251-0487
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2026
Last Update Date	:	01/12/2026

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