Healthcare Provider Details

I. General information

NPI: 1376096487
Provider Name (Legal Business Name): JACQUELINE LEE CHACE COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUELINE LEE JAHNKE

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 N VILLA CT #206
PALM SPRINGS CA
92262-0669
US

IV. Provider business mailing address

10 FENNER ST
CRANSTON RI
02910
US

V. Phone/Fax

Practice location:
  • Phone: 401-368-2588
  • Fax:
Mailing address:
  • Phone: 401-368-2588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3512
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: