Provider Demographics
NPI:1609358373
Name:JOHAL-MORALES, JACQUELINE ANN
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:JOHAL-MORALES
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 1:3569 ROUND BARN CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-5784
Mailing Address - Country:US
Mailing Address - Phone:707-583-8800
Mailing Address - Fax:
Practice Address - Street 1:3569 ROUND BARN CIR STE 200
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-5784
Practice Address - Country:US
Practice Address - Phone:707-583-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program