Provider Demographics
NPI:1053543694
Name:GEORGE, JACQUELYN LUCILLE (LAC)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:LUCILLE
Last Name:GEORGE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 FOREST LAKE RD
Mailing Address - Street 2:
Mailing Address - City:FRIENDSHIP
Mailing Address - State:ME
Mailing Address - Zip Code:04547-4205
Mailing Address - Country:US
Mailing Address - Phone:207-542-4737
Mailing Address - Fax:
Practice Address - Street 1:7 LIMEROCK ST
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-2928
Practice Address - Country:US
Practice Address - Phone:207-542-4737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-16
Last Update Date:2009-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC329171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist