Provider Demographics
NPI:1356856629
Name:UNZICKER, JACQUELINE AULD
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:AULD
Last Name:UNZICKER
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 1:1100 SW HARRIER CIR APT 4
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-2421
Mailing Address - Country:US
Mailing Address - Phone:850-293-5111
Mailing Address - Fax:
Practice Address - Street 1:840 SE BAYSHORE DR STE 101C
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-4062
Practice Address - Country:US
Practice Address - Phone:850-293-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60788607225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist