1083619563 NPI number — JACQUELIN S DANIEL CNP

Table of content: JACQUELIN S DANIEL CNP (NPI 1083619563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083619563 NPI number — JACQUELIN S DANIEL CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DANIEL
Provider First Name:
JACQUELIN
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083619563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1508 K-V ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VICTORIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23974
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-696-2165
Provider Business Mailing Address Fax Number:
434-696-1557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1508 K-V ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VICTORIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23974
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-696-2165
Provider Business Practice Location Address Fax Number:
434-696-1577
Provider Enumeration Date:
06/20/2005

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: 363LF0000X , with the licence number:  0024164095 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LW0102X , with the licence number: 0024164095 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 7000967 . This is a "NC MEDICAID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 187699 . This is a "MEDCOST CC" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 187620 . This is a "MEDCOST" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 010025788 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010252881 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010025788 . This is a "VA PREMIER KB" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 010105510 . This is a "VA PREMIER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 187697 . This is a "MEDCOST KB" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 224189800 . This is a "DOL" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 010105510 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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