Provider Demographics
NPI:1265077903
Name:CARRASCO, JAQUELINE (MA-C)
Entity type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:
Last Name:CARRASCO
Suffix:
Gender:F
Credentials:MA-C
Other - Prefix:
Other - First Name:JAQUELINE
Other - Middle Name:
Other - Last Name:CANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8140
Mailing Address - Country:US
Mailing Address - Phone:360-353-9828
Mailing Address - Fax:360-577-0269
Practice Address - Street 1:2700 SIMPSON AVE STE 101
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-4333
Practice Address - Country:US
Practice Address - Phone:360-612-0012
Practice Address - Fax:360-532-0670
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACM60504139376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACM60504139OtherMA LICENSE