Provider Demographics
NPI:1619215308
Name:BARRY, JACQUELINE DEBORAH (LICAC)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:DEBORAH
Last Name:BARRY
Suffix:
Gender:F
Credentials:LICAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11474 IAGER BLVD
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2507
Mailing Address - Country:US
Mailing Address - Phone:443-820-8253
Mailing Address - Fax:
Practice Address - Street 1:10705 CHARTER DR STE 420
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2800
Practice Address - Country:US
Practice Address - Phone:443-820-8253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-30
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02025171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist