Provider Demographics
NPI:1629673116
Name:LACY, JESSE LYNN
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:LYNN
Last Name:LACY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 ALLOWAY FRIESBURG RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-5527
Mailing Address - Country:US
Mailing Address - Phone:609-805-2578
Mailing Address - Fax:
Practice Address - Street 1:335 ALLOWAY FRIESBURG RD
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-5527
Practice Address - Country:US
Practice Address - Phone:609-805-2578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program