1699392266 NPI number — DR. JACQUELINE SURESH LAYTON PH.D.

Table of content: DR. JACQUELINE SURESH LAYTON PH.D. (NPI 1699392266)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699392266 NPI number — DR. JACQUELINE SURESH LAYTON PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAYTON
Provider First Name:
JACQUELINE
Provider Middle Name:
SURESH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CASTON
Provider Other First Name:
JACQUELINE
Provider Other Middle Name:
SURESH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699392266
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17324 GLENCOE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55044-7429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-718-0620
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17324 GLENCOE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55044-7429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-718-0620
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2020

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: 103TC0700X , with the licence number:  1085359 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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