Provider Demographics
NPI:1184210908
Name:LACEY, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LACEY
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 1:210 N TUBB ST UNIT 539
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34760-9022
Mailing Address - Country:US
Mailing Address - Phone:484-885-8609
Mailing Address - Fax:
Practice Address - Street 1:111 E MONUMENT AVE UNIT 412
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5774
Practice Address - Country:US
Practice Address - Phone:407-930-4711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor