Provider Demographics
NPI:1104209246
Name:DACOSTA, JACQUELINE ANGELA (RN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANGELA
Last Name:DACOSTA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4133 CHAPEL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-3568
Mailing Address - Country:US
Mailing Address - Phone:404-549-8086
Mailing Address - Fax:404-549-8086
Practice Address - Street 1:4133 CHAPEL LAKE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-3568
Practice Address - Country:US
Practice Address - Phone:404-549-8086
Practice Address - Fax:404-549-8086
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN079303163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse