MEDICARE: JACQUELINE MICHELLE STACY PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA 2347	AR
2	225200000X	Physical Therapy Assistant	4268	NC

General Provider Information

NPI Number	:	1144556259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE MICHELLE STACY PTA

Provider Business Mailing Address
First Line	:	140 RAILROAD ST
Second Line	:	P.O. BOX 564
City	:	TYRONZA
State	:	AR
Zip	:	72386-9416
Country	:	US
Telephone Number	:	870-514-9722
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 W 13TH ST
Second Line	:
City	:	MURFREESBORO
State	:	AR
Zip	:	71958-9501
Country	:	US
Telephone Number	:	870-285-2168
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2009
Last Update Date	:	10/24/2009

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