Provider Demographics
NPI:1518373414
Name:HARGETT, JACQLYN (LPN)
Entity Type:Individual
Prefix:
First Name:JACQLYN
Middle Name:
Last Name:HARGETT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:JACQLYN
Other - Middle Name:
Other - Last Name:ORTEGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:2539 N 48TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008
Mailing Address - Country:US
Mailing Address - Phone:602-405-8793
Mailing Address - Fax:
Practice Address - Street 1:2539 N 48TH PL
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008
Practice Address - Country:US
Practice Address - Phone:602-405-8793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-11
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP049662164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse