Provider Demographics
NPI:1285105163
Name:HAYNES, JACQUILINE MORGAN
Entity type:Individual
Prefix:
First Name:JACQUILINE
Middle Name:MORGAN
Last Name:HAYNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9820 PATRICIAN DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-5730
Mailing Address - Country:US
Mailing Address - Phone:727-488-7499
Mailing Address - Fax:727-945-0447
Practice Address - Street 1:9820 PATRICIAN DR
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34655-5730
Practice Address - Country:US
Practice Address - Phone:727-488-7499
Practice Address - Fax:727-945-0447
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015754900Medicaid