Healthcare Provider Details

I. General information

NPI: 1285760462
Provider Name (Legal Business Name): JACQUELINE CAROL HAGERTY RDH,RDHAP, MBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 SHASTA ACRES RD
MOUNT SHASTA CA
96067-9445
US

IV. Provider business mailing address

1921 SHASTA ACRES RD
MOUNT SHASTA CA
96067-9445
US

V. Phone/Fax

Practice location:
  • Phone: 530-926-5253
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberRDHAP99
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: