Provider Demographics
NPI:1144556259
Name:STACY, JACQUELINE MICHELLE (PTA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MICHELLE
Last Name:STACY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 RAILROAD ST
Mailing Address - Street 2:P.O. BOX 564
Mailing Address - City:TYRONZA
Mailing Address - State:AR
Mailing Address - Zip Code:72386-9416
Mailing Address - Country:US
Mailing Address - Phone:870-514-9722
Mailing Address - Fax:
Practice Address - Street 1:110 W 13TH ST
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:AR
Practice Address - Zip Code:71958-9501
Practice Address - Country:US
Practice Address - Phone:870-285-2168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-23
Last Update Date:2009-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 2347225200000X
NC4268225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant