Provider Demographics
NPI:1285127340
Name:PUOPOLO, JACKLYN MARIE
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:MARIE
Last Name:PUOPOLO
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 1:2201 WILSON BLVD APT 223
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-3374
Mailing Address - Country:US
Mailing Address - Phone:502-724-3243
Mailing Address - Fax:
Practice Address - Street 1:658 BOULTON ST
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4214
Practice Address - Country:US
Practice Address - Phone:410-638-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program