1467466417 NPI number — JACQUELINE HAGENBUCH APRN-C

Table of content: JACQUELINE HAGENBUCH APRN-C (NPI 1467466417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467466417 NPI number — JACQUELINE HAGENBUCH APRN-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAGENBUCH
Provider First Name:
JACQUELINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HAGENBUCH
Provider Other First Name:
JACKIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN-C
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1467466417
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 SEABOARD LN STE 200B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37067-8282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-793-7050
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4800 DEERWOOD CAMPUS PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32246-8317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-793-7050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2006

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: 363L00000X , with the licence number:  ARNP3290112 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: APRN3290112 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 116558100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".