Provider Demographics
NPI:1053870857
Name:STANSELL, JACQUELYNN NICHOLE
Entity type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:NICHOLE
Last Name:STANSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELYNN
Other - Middle Name:N
Other - Last Name:WOLFHEART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1160 LUMINARY CIR UNIT 101
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-7834
Mailing Address - Country:US
Mailing Address - Phone:208-991-8952
Mailing Address - Fax:
Practice Address - Street 1:1877 ELKINS POINT DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4762
Practice Address - Country:US
Practice Address - Phone:208-991-8952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist