Provider Demographics
NPI:1730523341
Name:DAVIS, JACQUELINE (LPN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 STABORN DR
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2737
Mailing Address - Country:US
Mailing Address - Phone:608-346-2301
Mailing Address - Fax:
Practice Address - Street 1:2305 STABORN DR
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2737
Practice Address - Country:US
Practice Address - Phone:608-346-2301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30452-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse