Provider Demographics
NPI:1669687257
Name:LOCK, JACQUELINE LOLETA (LMT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LOLETA
Last Name:LOCK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5974 NW 29TH PL
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33313-1202
Mailing Address - Country:US
Mailing Address - Phone:954-478-1341
Mailing Address - Fax:
Practice Address - Street 1:5974 NW 29TH PL
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33313-1202
Practice Address - Country:US
Practice Address - Phone:954-478-1341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA43354171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor