Provider Demographics
NPI:1891091732
Name:MEMMINGER, JACQUELINE (MOT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MEMMINGER
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:MEMMINGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MOT
Mailing Address - Street 1:5638 SWAMP FOX RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-7312
Mailing Address - Country:US
Mailing Address - Phone:904-294-3990
Mailing Address - Fax:
Practice Address - Street 1:250 NW 76TH DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-6668
Practice Address - Country:US
Practice Address - Phone:352-505-6363
Practice Address - Fax:352-505-6383
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMOT14504174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist