1386964997 NPI number — MRS. NICOLE JACARUSO SKINNER PT

Table of content: MRS. NICOLE JACARUSO SKINNER PT (NPI 1386964997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386964997 NPI number — MRS. NICOLE JACARUSO SKINNER PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SKINNER
Provider First Name:
NICOLE
Provider Middle Name:
JACARUSO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACARUSO
Provider Other First Name:
NICOLE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1386964997
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10555 PINE FALLS CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92131-1360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-437-6450
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10555 PINE FALLS CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-917-8738
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT18043 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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