Provider Demographics
NPI:1265511455
Name:JAQUA, COLLEEN CAROL (REGISTERED NURSE)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:CAROL
Last Name:JAQUA
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2092 DONNOVAN AVE
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:CA
Mailing Address - Zip Code:96021-2701
Mailing Address - Country:US
Mailing Address - Phone:530-824-3942
Mailing Address - Fax:
Practice Address - Street 1:1445 VISTA WAY
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-4510
Practice Address - Country:US
Practice Address - Phone:530-527-8491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA281097163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse