Healthcare Provider Details

I. General information

NPI: 1144504887
Provider Name (Legal Business Name): JACQUELINE DAYLE WATERS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUELINE DAYLE DECICCO

II. Dates (important events)

Enumeration Date: 09/29/2011
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 N LAS VEGAS BLVD
NORTH LAS VEGAS NV
89030-5803
US

IV. Provider business mailing address

2251 E HANCOCK ST STE 100
NEWBERG OR
97132-2145
US

V. Phone/Fax

Practice location:
  • Phone: 702-649-1415
  • Fax:
Mailing address:
  • Phone: 971-281-3060
  • Fax: 971-281-3061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0018868
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: