Provider Demographics
NPI:1891762662
Name:DAITOL, JACKITO JUGAN (NP)
Entity Type:Individual
Prefix:
First Name:JACKITO
Middle Name:JUGAN
Last Name:DAITOL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:JUGAN
Other - Last Name:DAITOL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:801 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ROSELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07204-1350
Mailing Address - Country:US
Mailing Address - Phone:908-245-0604
Mailing Address - Fax:
Practice Address - Street 1:385 TREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-1023
Practice Address - Country:US
Practice Address - Phone:973-676-1000
Practice Address - Fax:973-395-7003
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN09365100363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health