Provider Demographics
NPI:1619038775
Name:LACY, JESSE M (DC)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:M
Last Name:LACY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 PARKER ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-7422
Mailing Address - Country:US
Mailing Address - Phone:321-726-0168
Mailing Address - Fax:
Practice Address - Street 1:1900 PALM BAY ROAD NORTHEAST
Practice Address - Street 2:SUITE C
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2955
Practice Address - Country:US
Practice Address - Phone:321-726-0168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0005634111N00000X
GACHIR004995111N00000X
AL1523111N00000X
TNDC0000001066111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U31145Medicare UPIN
22527AMedicare ID - Type Unspecified