Provider Demographics
NPI:1750645958
Name:JAQUIN, KATIE ROSE
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:ROSE
Last Name:JAQUIN
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 1:301 RUGBY RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1442
Mailing Address - Country:US
Mailing Address - Phone:315-474-8142
Mailing Address - Fax:
Practice Address - Street 1:6575 KIRKVILLE RD
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9809
Practice Address - Country:US
Practice Address - Phone:315-701-5710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist