Provider Demographics
NPI:1134874985
Name:CARDONA, JAQUELINE
Entity type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:
Last Name:CARDONA
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 1:1757 GLENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5913
Mailing Address - Country:US
Mailing Address - Phone:707-596-2182
Mailing Address - Fax:
Practice Address - Street 1:850 W 9TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5349
Practice Address - Country:US
Practice Address - Phone:707-890-3940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other