Provider Demographics
NPI:1063663045
Name:MOGHADDAM, JACQUELENE FARRAH (MED)
Entity type:Individual
Prefix:MISS
First Name:JACQUELENE
Middle Name:FARRAH
Last Name:MOGHADDAM
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 LAWRENCE ST
Mailing Address - Street 2:APARTMENT 3
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-8812
Mailing Address - Country:US
Mailing Address - Phone:714-872-1947
Mailing Address - Fax:
Practice Address - Street 1:815 LAWRENCE ST
Practice Address - Street 2:APARTMENT 3
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-8812
Practice Address - Country:US
Practice Address - Phone:714-872-1947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program