Provider Demographics
NPI:1023672748
Name:JANCEK, JACQUELINE IRENE (CLC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:IRENE
Last Name:JANCEK
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 WENDEL AVE
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-2079
Mailing Address - Country:US
Mailing Address - Phone:813-520-8984
Mailing Address - Fax:
Practice Address - Street 1:310 WENDEL AVE
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-2079
Practice Address - Country:US
Practice Address - Phone:813-520-8984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL308480174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN