Provider Demographics
NPI:1740831767
Name:COGHILL, JACQUELINE RENEE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RENEE
Last Name:COGHILL
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 1:3126 J ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-5416
Mailing Address - Country:US
Mailing Address - Phone:707-599-6736
Mailing Address - Fax:
Practice Address - Street 1:WATERFRONT RECOVERY SERVICES
Practice Address - Street 2:2413 2ND ST
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501
Practice Address - Country:US
Practice Address - Phone:707-269-9590
Practice Address - Fax:707-445-2599
Is Sole Proprietor?:No
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012163363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1417307125OtherMEDICAL DOCTOR