Provider Demographics
NPI:1568538643
Name:KEENAN KINCAID, JACQUELINE (LMT)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:KEENAN KINCAID
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4781 N CONGRESS AVE
Mailing Address - Street 2:#186
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-7941
Mailing Address - Country:US
Mailing Address - Phone:561-389-4377
Mailing Address - Fax:561-292-2155
Practice Address - Street 1:7950 S MILITARY TRL
Practice Address - Street 2:SUITE 103
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-8162
Practice Address - Country:US
Practice Address - Phone:561-389-4377
Practice Address - Fax:561-292-2155
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA13932225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL687987096Medicaid