Provider Demographics
NPI:1003084369
Name:REVELLO, JACQUELINE (MA, RN)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:REVELLO
Suffix:
Gender:F
Credentials:MA, RN
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, RN
Mailing Address - Street 1:PO BOX 214
Mailing Address - Street 2:682 SIMBA POINT
Mailing Address - City:DIVIDE
Mailing Address - State:CO
Mailing Address - Zip Code:80814-0214
Mailing Address - Country:US
Mailing Address - Phone:719-687-4224
Mailing Address - Fax:
Practice Address - Street 1:11115 W. HWY 24, UNIT 2C
Practice Address - Street 2:
Practice Address - City:DIVIDE
Practice Address - State:CO
Practice Address - Zip Code:80814
Practice Address - Country:US
Practice Address - Phone:719-687-6416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-20
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CORN0188325163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101Y00000XBehavioral Health & Social Service ProvidersCounselor