Provider Demographics
NPI:1376096487
Name:CHACE, JACQUELINE LEE (COTA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LEE
Last Name:CHACE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:LEE
Other - Last Name:JAHNKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 FENNER ST
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910
Mailing Address - Country:US
Mailing Address - Phone:401-368-2588
Mailing Address - Fax:
Practice Address - Street 1:470 N VILLA CT
Practice Address - Street 2:#206
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-0669
Practice Address - Country:US
Practice Address - Phone:401-368-2588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3512314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility