Provider Demographics
NPI:1528050994
Name:BABOL, JACQUELINE MENDOZA (DPM)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MENDOZA
Last Name:BABOL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9116 E SPRAGUE AVE
Mailing Address - Street 2:#278
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99206
Mailing Address - Country:US
Mailing Address - Phone:509-928-8181
Mailing Address - Fax:208-772-9949
Practice Address - Street 1:205 N UNIVERSITY
Practice Address - Street 2:#4
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99206
Practice Address - Country:US
Practice Address - Phone:509-928-8181
Practice Address - Fax:208-772-9949
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2015-11-10
Deactivation Date:2005-08-22
Deactivation Code:
Reactivation Date:2007-09-07
Provider Licenses
StateLicense IDTaxonomies
WAPO00000715213E00000X
IDP218213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1116623Medicaid
WA1116623Medicaid
WA4797370001Medicare NSC
WAU37750Medicare UPIN