Provider Demographics
NPI:1679129902
Name:MEYERS, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MEYERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:MOREDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:MANAGED CARE DEPT
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805
Mailing Address - Country:US
Mailing Address - Phone:863-687-1100
Mailing Address - Fax:
Practice Address - Street 1:3644 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-4105
Practice Address - Country:US
Practice Address - Phone:863-687-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113268363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant