1013382712 NPI number — JACLYN GOSSMAN HAUGE L.M., C.P.M

Table of content: JACLYN GOSSMAN HAUGE L.M., C.P.M (NPI 1013382712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013382712 NPI number — JACLYN GOSSMAN HAUGE L.M., C.P.M

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAUGE
Provider First Name:
JACLYN
Provider Middle Name:
GOSSMAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.M., C.P.M
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOSSMAN
Provider Other First Name:
JACLYN
Provider Other Middle Name:
DIANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013382712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2593 SHEFFIELD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELTONA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32738-8808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-620-2662
Provider Business Mailing Address Fax Number:
407-264-8508

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2593 SHEFFIELD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELTONA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32738-8808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-620-2662
Provider Business Practice Location Address Fax Number:
407-264-8508
Provider Enumeration Date:
12/07/2015

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: 176B00000X , with the licence number:  MW319 , 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)





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