Provider Demographics
NPI:1083960975
Name:VELASCO, JACKIE LYN DAVID (RPH)
Entity Type:Individual
Prefix:
First Name:JACKIE LYN
Middle Name:DAVID
Last Name:VELASCO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-5631
Mailing Address - Country:US
Mailing Address - Phone:916-868-5996
Mailing Address - Fax:
Practice Address - Street 1:1220 BROADWAY
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-5806
Practice Address - Country:US
Practice Address - Phone:530-626-5501
Practice Address - Fax:530-626-6147
Is Sole Proprietor?:No
Enumeration Date:2012-07-28
Last Update Date:2012-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65167183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist