Provider Demographics
NPI:1598166118
Name:MOTON, JAQUARY (LPN)
Entity Type:Individual
Prefix:
First Name:JAQUARY
Middle Name:
Last Name:MOTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3648 UTOY DR SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-8617
Mailing Address - Country:US
Mailing Address - Phone:917-407-8524
Mailing Address - Fax:
Practice Address - Street 1:3648 UTOY DR SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-8617
Practice Address - Country:US
Practice Address - Phone:917-407-8524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN074491164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse