Provider Demographics
NPI:1982375952
Name:PACKARD, JACQUELYN LEE
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:LEE
Last Name:PACKARD
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 1:308 SKYLARK DR
Mailing Address - Street 2:
Mailing Address - City:CORAOPOLIS
Mailing Address - State:PA
Mailing Address - Zip Code:15108-8926
Mailing Address - Country:US
Mailing Address - Phone:724-554-6274
Mailing Address - Fax:
Practice Address - Street 1:1011 BINGHAM ST
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15203-1101
Practice Address - Country:US
Practice Address - Phone:412-235-5494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-20-40602103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst