Provider Demographics
NPI:1710024393
Name:GRACE, JEANIE (PHD, AP, LAC)
Entity Type:Individual
Prefix:DR
First Name:JEANIE
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:PHD, AP, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 SPRING VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-1718
Mailing Address - Country:US
Mailing Address - Phone:321-890-2082
Mailing Address - Fax:
Practice Address - Street 1:3700 N HARBOR CITY BLVD STE 2B
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5792
Practice Address - Country:US
Practice Address - Phone:321-890-2082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 5272171100000X
FLAP3591171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist