Basic Information
| Provider Information | |||||||||
| NPI: | 1366810301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEALEY | ||||||||
| FirstName: | JACQUELYNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 579 | ||||||||
| Address2: | |||||||||
| City: | SUMMIT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396660579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012763900 | ||||||||
| FaxNumber: | 6012763939 | ||||||||
| Practice Location | |||||||||
| Address1: | 1784 ELKAHATCHEE RD | ||||||||
| Address2: | |||||||||
| City: | ALEXANDER CITY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350104800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563290868 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2015 | ||||||||
| LastUpdateDate: | 09/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 7494 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.