Provider Demographics
NPI:1619043684
Name:BRICENO, JACKELINE D (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKELINE
Middle Name:D
Last Name:BRICENO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2221 SE OCEAN BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34996-3341
Mailing Address - Country:US
Mailing Address - Phone:772-283-4428
Mailing Address - Fax:772-288-0192
Practice Address - Street 1:2221 SE OCEAN BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996-3341
Practice Address - Country:US
Practice Address - Phone:772-283-4428
Practice Address - Fax:772-288-0192
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75870174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG85125Medicare UPIN
FL1619043684Medicare PIN