Provider Demographics
NPI:1689900169
Name:SHARP, JACQUELINE MICHELE (LCMT)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:MICHELE
Last Name:SHARP
Suffix:
Gender:F
Credentials:LCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-5224
Mailing Address - Country:US
Mailing Address - Phone:815-243-9366
Mailing Address - Fax:
Practice Address - Street 1:2204 ARTHUR AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-5224
Practice Address - Country:US
Practice Address - Phone:815-243-9366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227003425174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist