Provider Demographics
NPI:1235397258
Name:DE LA GRANA, JACKELINE A
Entity Type:Individual
Prefix:
First Name:JACKELINE
Middle Name:A
Last Name:DE LA GRANA
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 1:4444 SW 136TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3721
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1490 W 49TH PL
Practice Address - Street 2:SUITE 210
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3148
Practice Address - Country:US
Practice Address - Phone:305-823-4008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA50607246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other