Provider Demographics
NPI:1184344525
Name:DOUGLAS, JEANNIE LASLO (AP, DIPL OM, ERYT)
Entity type:Individual
Prefix:
First Name:JEANNIE
Middle Name:LASLO
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:AP, DIPL OM, ERYT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 DUNLAWTON AVE APT 1924
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-7923
Mailing Address - Country:US
Mailing Address - Phone:541-639-2618
Mailing Address - Fax:
Practice Address - Street 1:316 DUNLAWTON AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4456
Practice Address - Country:US
Practice Address - Phone:386-872-5757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4301171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist