MEDICARE: JACY LEE MCPHERSON

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	390200000X	Student in an Organized Health Care Education/Training Program	S12760	AL

General Provider Information

NPI Number	:	1578193082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACY LEE MCPHERSON

Provider Business Mailing Address
First Line	:	2791 COUNTY ROAD 89
Second Line	:
City	:	FORT PAYNE
State	:	AL
Zip	:	35967-6147
Country	:	US
Telephone Number	:	256-630-1279
Fax Number	:

Provider Business Practice Location Address
First Line	:	2791 COUNTY ROAD 89
Second Line	:
City	:	FORT PAYNE
State	:	AL
Zip	:	35967-6147
Country	:	US
Telephone Number	:	256-630-1279
Fax Number	:

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

Provider Enumeration Date	:	01/23/2020
Last Update Date	:	01/23/2020

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