Provider Demographics
NPI:1225851538
Name:VICKERS, JACQUELINE PATRICE (MED)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:PATRICE
Last Name:VICKERS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:PATRICE
Other - Last Name:VICKERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED
Mailing Address - Street 1:2137 TEHAMA CT
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3079
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2137 TEHAMA CT
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3079
Practice Address - Country:US
Practice Address - Phone:863-430-7307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist