Provider Demographics
NPI:1083482061
Name:TOBIN, JACQUELINE GRACE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:GRACE
Last Name:TOBIN
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 1:173 RUTLEDGE AVE APT B
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5815
Mailing Address - Country:US
Mailing Address - Phone:843-816-1953
Mailing Address - Fax:
Practice Address - Street 1:173 RUTLEDGE AVE APT B
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5815
Practice Address - Country:US
Practice Address - Phone:843-816-1953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program