Provider Demographics
NPI:1316252042
Name:BRUCE-TAGOE, JACQUELINE O
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:O
Last Name:BRUCE-TAGOE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:O
Other - Last Name:BRUCE-TAGOE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:15816 MEHERRIN WAY
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-4264
Mailing Address - Country:US
Mailing Address - Phone:703-919-5815
Mailing Address - Fax:
Practice Address - Street 1:15816 MEHERRIN WAY
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-4264
Practice Address - Country:US
Practice Address - Phone:703-919-5815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002073930164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse