Provider Demographics
NPI:1689913519
Name:FONCHAM, JACKLINE
Entity Type:Individual
Prefix:
First Name:JACKLINE
Middle Name:
Last Name:FONCHAM
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 1:13703 MODRAD WAY
Mailing Address - Street 2:APT. # 23
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-4825
Mailing Address - Country:US
Mailing Address - Phone:202-291-7226
Mailing Address - Fax:
Practice Address - Street 1:439 ONEIDA PL NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-2150
Practice Address - Country:US
Practice Address - Phone:202-291-7226
Practice Address - Fax:202-291-4009
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC036061400Medicaid