Provider Demographics
NPI:1083938138
Name:MARIN, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MARIN
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 1:994 S HARRISON RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85748-6608
Mailing Address - Country:US
Mailing Address - Phone:520-721-1887
Mailing Address - Fax:
Practice Address - Street 1:17688 S VERMILLION SUNSET DR
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:AZ
Practice Address - Zip Code:85641-2733
Practice Address - Country:US
Practice Address - Phone:520-207-4210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2152273171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor