Provider Demographics
NPI:1316780745
Name:WEISEL, JACQULYN
Entity type:Individual
Prefix:
First Name:JACQULYN
Middle Name:
Last Name:WEISEL
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 1:3144 OLD FRANKLIN RD APT 6101
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-4798
Mailing Address - Country:US
Mailing Address - Phone:848-245-6781
Mailing Address - Fax:
Practice Address - Street 1:1324 HAZELWOOD DR
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-3922
Practice Address - Country:US
Practice Address - Phone:615-247-6831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist