Provider Demographics
NPI:1336608942
Name:JACQUELYN MACEY PA-C LLC
Entity Type:Organization
Organization Name:JACQUELYN MACEY PA-C LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:MACEY
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:850-582-1221
Mailing Address - Street 1:1105 TOWN BLVD NE UNIT 2302
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3662
Mailing Address - Country:US
Mailing Address - Phone:850-582-1221
Mailing Address - Fax:
Practice Address - Street 1:2400 WISTERIA DR STE A
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2689
Practice Address - Country:US
Practice Address - Phone:770-985-9330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty