Provider Demographics
NPI:1710457379
Name:DAGOSTINO, JACQUELINE RAE (DPT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RAE
Last Name:DAGOSTINO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 W WASHINGTON ST STE B
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89703-3828
Mailing Address - Country:US
Mailing Address - Phone:775-882-5001
Mailing Address - Fax:775-882-5015
Practice Address - Street 1:604 W WASHINGTON ST STE B
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-3828
Practice Address - Country:US
Practice Address - Phone:775-882-5001
Practice Address - Fax:775-882-5015
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT295756225100000X
NV6216225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist