Provider Demographics
NPI:1700464757
Name:DOLIN, JACQUE MICHELLE
Entity Type:Individual
Prefix:
First Name:JACQUE
Middle Name:MICHELLE
Last Name:DOLIN
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 1:9 THORNHILL ESTS
Mailing Address - Street 2:
Mailing Address - City:POCA
Mailing Address - State:WV
Mailing Address - Zip Code:25159-9407
Mailing Address - Country:US
Mailing Address - Phone:304-410-2442
Mailing Address - Fax:
Practice Address - Street 1:9 THORNHILL ESTS
Practice Address - Street 2:
Practice Address - City:POCA
Practice Address - State:WV
Practice Address - Zip Code:25159-9407
Practice Address - Country:US
Practice Address - Phone:304-410-2442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant