Healthcare Provider Details

I. General information

NPI: 1043776875
Provider Name (Legal Business Name): DR. JACLYN VICTORIA NEBZYDOSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. JACLYN VICTORIA GASSAWAY

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 09/25/2024
Certification Date: 09/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US NAVAL HOSPITAL GUAM FARENHOLT AVE, BLDG 50
AGANA HEIGHTS GU
96910
US

IV. Provider business mailing address

PSC 455 BOX 208
FPO AP
96540-0003
US

V. Phone/Fax

Practice location:
  • Phone: 671-344-9340
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0102206234
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: