Provider Demographics
NPI:1205378668
Name:MARGOLESE, JACQUELINE (MSN, FNP-C, AG-ACNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MARGOLESE
Suffix:
Gender:F
Credentials:MSN, FNP-C, AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20103 LAKE CHABOT RD
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5305
Mailing Address - Country:US
Mailing Address - Phone:510-727-2759
Mailing Address - Fax:
Practice Address - Street 1:20103 LAKE CHABOT RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5305
Practice Address - Country:US
Practice Address - Phone:510-727-2759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-15
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008327363L00000X
HIAPRN-2206363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherN/A