1588109250 NPI number — JACLYN FAESTEL RN

Table of content: JACLYN FAESTEL RN (NPI 1588109250)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588109250 NPI number — JACLYN FAESTEL RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAESTEL
Provider First Name:
JACLYN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOOD
Provider Other First Name:
JACLYN
Provider Other Middle Name:
STEPHANY
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:
1588109250
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6222 GRAND FIR DR SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCCHORD AFB
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98439-2200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-284-7055
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MADIGAN ARMY MEDICAL CTR
Provider Second Line Business Practice Location Address:
9040 JACKSON AVE, ATTN: MCHJ-CLQ-C
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98431-1100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-968-3869
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/04/2017

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: 163W00000X , with the licence number:  664512-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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