Provider Demographics
NPI:1174944797
Name:LUSK, JACQUELYN
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:LUSK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22A MECHANIC ST
Mailing Address - Street 2:
Mailing Address - City:HOLLEY
Mailing Address - State:NY
Mailing Address - Zip Code:14470-1157
Mailing Address - Country:US
Mailing Address - Phone:585-283-1124
Mailing Address - Fax:
Practice Address - Street 1:22A MECHANIC ST
Practice Address - Street 2:
Practice Address - City:HOLLEY
Practice Address - State:NY
Practice Address - Zip Code:14470-1157
Practice Address - Country:US
Practice Address - Phone:585-283-1124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-27
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY247778-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse