Provider Demographics
NPI:1528459393
Name:COUCH, JACQUELINE (CNA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:COUCH
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:MRS
Other - First Name:JACQUELINE
Other - Middle Name:DENISE
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA
Mailing Address - Street 1:2594 NW 152ND ST
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-4533
Mailing Address - Country:US
Mailing Address - Phone:515-987-8155
Mailing Address - Fax:
Practice Address - Street 1:2594 NW 152ND ST
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-4533
Practice Address - Country:US
Practice Address - Phone:515-987-8155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-13
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA257401172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker