MEDICARE: JACQUELINE SUSAN HARTE L.AC

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	171100000X	Acupuncturist	0166	AZ

General Provider Information

NPI Number	:	1831392604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE SUSAN HARTE L.AC

Provider Business Mailing Address
First Line	:	1916 W WOODLAND LAKE RD
Second Line	:
City	:	LAKESIDE
State	:	AZ
Zip	:	85929-6470
Country	:	US
Telephone Number	:	928-367-2551
Fax Number	:

Provider Business Practice Location Address
First Line	:	1916 W WOODLAND LAKE RD
Second Line	:
City	:	LAKESIDE
State	:	AZ
Zip	:	85929-6470
Country	:	US
Telephone Number	:	928-367-2551
Fax Number	:

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

Provider Enumeration Date	:	06/07/2007
Last Update Date	:	07/08/2007

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