Provider Demographics
NPI:1073136537
Name:SANDOLE, JACQUELINE MARIE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:SANDOLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7311 E SOUTHERN AVE APT 3032
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-2720
Mailing Address - Country:US
Mailing Address - Phone:160-257-5774
Mailing Address - Fax:
Practice Address - Street 1:7311 E SOUTHERN AVE APT 3032
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-2720
Practice Address - Country:US
Practice Address - Phone:160-257-5774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ008558227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ008850OtherRESPIRATORY
008850OtherRESPIRATORY