Provider Demographics
NPI:1316550387
Name:OHAGAN, JACQUELINE MARIE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:OHAGAN
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 1:119 WHITNEY ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-4803
Mailing Address - Country:US
Mailing Address - Phone:805-231-3877
Mailing Address - Fax:
Practice Address - Street 1:2120 ALPINE BLVD
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-2113
Practice Address - Country:US
Practice Address - Phone:619-445-2644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000000OtherDO NOT HAVE ONE