Healthcare Provider Details

I. General information

NPI: 1619899606
Provider Name (Legal Business Name): STACEY JACKLYN LEVESQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 HALE ST
BEVERLY MA
01915-2096
US

IV. Provider business mailing address

69 HANCOCK ST
READING MA
01867-2321
US

V. Phone/Fax

Practice location:
  • Phone: 781-382-8719
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: