Provider Demographics
NPI:1508331893
Name:MCMATH, JACQUELINE D (RN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:D
Last Name:MCMATH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:D
Other - Last Name:MCMATH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:4534 S 79TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-1011
Mailing Address - Country:US
Mailing Address - Phone:253-278-4405
Mailing Address - Fax:
Practice Address - Street 1:4534 S 79TH ST STE A
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-1011
Practice Address - Country:US
Practice Address - Phone:253-278-4405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60023973163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty