Provider Demographics
NPI:1619268034
Name:EVANS, JACQUELINE MARIE (LMT)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:EVANS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:MARIE
Other - Last Name:GALARZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:3604 LAREDO DR
Mailing Address - Street 2:A
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-2173
Mailing Address - Country:US
Mailing Address - Phone:859-536-2038
Mailing Address - Fax:
Practice Address - Street 1:3604 LAREDO DR
Practice Address - Street 2:A
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-2173
Practice Address - Country:US
Practice Address - Phone:859-536-2038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4033225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist