Provider Demographics
NPI:1083818553
Name:NYSTROM, JACQUELYN H (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:H
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:9975 TAVISTOCK LAKE BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7559
Mailing Address - Country:US
Mailing Address - Phone:407-930-7901
Mailing Address - Fax:407-930-7806
Practice Address - Street 1:9975 TAVISTOCK LAKE BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7559
Practice Address - Country:US
Practice Address - Phone:407-930-7901
Practice Address - Fax:407-930-7806
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2015-02-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME94368207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine