Provider Demographics
NPI:1538208509
Name:STACY, JACQUELYN MARIE (LMT)
Entity type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:MARIE
Last Name:STACY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:JACKIE
Other - Middle Name:M
Other - Last Name:RICKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:1210 BRECKENRIDGE RUN
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-4060
Mailing Address - Country:US
Mailing Address - Phone:850-556-7009
Mailing Address - Fax:
Practice Address - Street 1:310 BLOUNT ST
Practice Address - Street 2:SUITE 203
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-2207
Practice Address - Country:US
Practice Address - Phone:850-556-7009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA-48657175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath