Provider Demographics
NPI:1104404615
Name:MORALES, JACQUELYN SUZANNE
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:SUZANNE
Last Name:MORALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 CEDARBEND RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-1825
Mailing Address - Country:US
Mailing Address - Phone:931-338-2599
Mailing Address - Fax:
Practice Address - Street 1:220 HIGHWAY 76
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4102
Practice Address - Country:US
Practice Address - Phone:931-552-0881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2412224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty