Healthcare Provider Details

I. General information

NPI: 1013000488
Provider Name (Legal Business Name): JACQUELINE M NOE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE MARSHIANO

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 CHILDRENS WAY NEMOURS CHILDRENS CLINIC, JACKSONVILLE
JACKSONVILLE FL
32207-8426
US

IV. Provider business mailing address

PO BOX 191 PROVIDER ENROLLMENT DEPT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 904-697-3600
  • Fax: 904-697-3792
Mailing address:
  • Phone: 302-651-6212
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL1873
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9107624
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: