Provider Demographics
NPI:1912601899
Name:GRAGG, JACQUELINE GAIL
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:GAIL
Last Name:GRAGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15422 ANCEL CIR
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33981-4213
Mailing Address - Country:US
Mailing Address - Phone:816-820-8033
Mailing Address - Fax:
Practice Address - Street 1:992 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33953-3868
Practice Address - Country:US
Practice Address - Phone:941-888-4710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23333225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist