Provider Demographics
NPI:1447946348
Name:FUSARI, JACQUELINE (LAC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FUSARI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 SIMSBURY RD # 1-J
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3743
Mailing Address - Country:US
Mailing Address - Phone:971-777-5331
Mailing Address - Fax:
Practice Address - Street 1:124 SIMSBURY RD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3743
Practice Address - Country:US
Practice Address - Phone:971-777-5331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT822171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist