Provider Demographics
NPI:1922545227
Name:BRACKEN, LACEY DENNIS (MS,LAT,ATC)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:DENNIS
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:MS,LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7491 MISHKIE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-8157
Mailing Address - Country:US
Mailing Address - Phone:770-778-1938
Mailing Address - Fax:
Practice Address - Street 1:1149 W 13TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-5610
Practice Address - Country:US
Practice Address - Phone:770-778-1938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLAL48632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program