Provider Demographics
NPI:1790251981
Name:AGUILAR, JADE NYCOLE
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:NYCOLE
Last Name:AGUILAR
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 1:5945 WATERSIDE DR APT 2
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-4933
Mailing Address - Country:US
Mailing Address - Phone:219-617-7855
Mailing Address - Fax:
Practice Address - Street 1:5945 WATERSIDE DR APT 2
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4933
Practice Address - Country:US
Practice Address - Phone:219-617-7855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE