Provider Demographics
NPI:1346591468
Name:CORP, JACQUELIN L (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JACQUELIN
Middle Name:L
Last Name:CORP
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:JACQUELIN
Other - Middle Name:L
Other - Last Name:MOLLOHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:PO BOX 5299
Mailing Address - Street 2:MS: 820-5-PCO
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0299
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4234
Practice Address - Country:US
Practice Address - Phone:253-403-1000
Practice Address - Fax:534-031-2232
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV78342363LF0000X
WAAP60834534363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV1947AMedicare PIN