Provider Demographics
NPI:1992164297
Name:FLEAGLE, JACQUELINE (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:FLEAGLE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:FLEAGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:3000 S STATE ROAD 135
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-9825
Mailing Address - Country:US
Mailing Address - Phone:317-535-4075
Mailing Address - Fax:
Practice Address - Street 1:3000 S STATE ROAD 135
Practice Address - Street 2:SUITE 110
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-9825
Practice Address - Country:US
Practice Address - Phone:317-535-4075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05011792A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist