Provider Demographics
NPI:1649446279
Name:JACUZZI, LEA SHANNON (DPT)
Entity type:Individual
Prefix:MRS
First Name:LEA
Middle Name:SHANNON
Last Name:JACUZZI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 N OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-8769
Mailing Address - Country:US
Mailing Address - Phone:501-993-0342
Mailing Address - Fax:
Practice Address - Street 1:9601 INTERSTATE 630 EXIT 7
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7202
Practice Address - Country:US
Practice Address - Phone:501-202-7614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-04
Last Update Date:2008-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 2684174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist