Provider Demographics
NPI:1013247782
Name:MYSAK, JAQUELYN M (CD(DONA))
Entity Type:Individual
Prefix:
First Name:JAQUELYN
Middle Name:M
Last Name:MYSAK
Suffix:
Gender:F
Credentials:CD(DONA)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 17TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-7785
Mailing Address - Country:US
Mailing Address - Phone:507-884-9424
Mailing Address - Fax:
Practice Address - Street 1:2413 17TH AVE NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-7785
Practice Address - Country:US
Practice Address - Phone:507-884-9424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-02
Last Update Date:2010-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula