Provider Demographics
NPI:1457489023
Name:LUCKE, JACQUELINE A (CCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:A
Last Name:LUCKE
Suffix:
Gender:F
Credentials:CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 830441
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34483-0441
Mailing Address - Country:US
Mailing Address - Phone:352-347-4380
Mailing Address - Fax:352-347-4380
Practice Address - Street 1:11202 SE 54TH AVE
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420-3959
Practice Address - Country:US
Practice Address - Phone:352-347-4380
Practice Address - Fax:352-347-4380
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 2731235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL882289100Medicaid