Provider Demographics
NPI:1184043572
Name:RIDDICK, JACQUELYN R (LAC)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:R
Last Name:RIDDICK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MS
Other - First Name:JACQUELYN
Other - Middle Name:R
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:394 HASBROUCK AVE #2C
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401
Mailing Address - Country:US
Mailing Address - Phone:845-750-4896
Mailing Address - Fax:
Practice Address - Street 1:394 HASBROUCK AVE.
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401
Practice Address - Country:US
Practice Address - Phone:845-750-4896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-14
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25 005208171100000X
NY019298-1225700000X
NY005208-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty