Provider Demographics
NPI:1235596461
Name:FREEMAN, JACQUELYN (PA)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:FREEMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:
Other - Last Name:STEMBRIDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 9033
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-9033
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-223-5665
Practice Address - Street 1:10050 SW INNOVATION WAY STE 102
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2117
Practice Address - Country:US
Practice Address - Phone:772-288-5862
Practice Address - Fax:772-288-5874
Is Sole Proprietor?:No
Enumeration Date:2016-01-19
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109326363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL5T3NOtherFLORIDA BLUE
FL016547300Medicaid
FLIM393YMedicare PIN