MEDICARE: JACKSON SANGUILY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	146N00000X	Basic Emergency Medical Technician	Q212354	CO

General Provider Information

NPI Number	:	1548009343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKSON SANGUILY

Provider Business Mailing Address
First Line	:	6 CARRIAGE WALK LN APT 342
Second Line	:
City	:	SCARBOROUGH
State	:	ME
Zip	:	04074-8296
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3827 N LAFAYETTE ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80205-5089
Country	:	US
Telephone Number	:	303-500-1518
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2024
Last Update Date	:	05/21/2024

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Directions to “ JACKSON SANGUILY ” Practice Location

Language	Start Address	Practice Location

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