Provider Demographics
NPI:1073142337
Name:LUCKE, JACQUELINE CLAUDIA (DPM)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:CLAUDIA
Last Name:LUCKE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 COUNTRYSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33763-1605
Mailing Address - Country:US
Mailing Address - Phone:727-797-5008
Mailing Address - Fax:
Practice Address - Street 1:2521 COUNTRYSIDE BLVD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33763-1605
Practice Address - Country:US
Practice Address - Phone:727-797-5008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO4496213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist