Provider Demographics
NPI:1578269635
Name:PERSON, JACQUELINE L
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:L
Last Name:PERSON
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 1:3505 RHODE ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT RAINIER
Mailing Address - State:MD
Mailing Address - Zip Code:20712-2004
Mailing Address - Country:US
Mailing Address - Phone:404-822-2163
Mailing Address - Fax:
Practice Address - Street 1:2126 32ND ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-3322
Practice Address - Country:US
Practice Address - Phone:202-638-9572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant