Provider Demographics
NPI:1053740480
Name:STAKER, JOCELYN M
Entity type:Individual
Prefix:
First Name:JOCELYN
Middle Name:M
Last Name:STAKER
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:PO BOX 272195
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80527-2195
Mailing Address - Country:US
Mailing Address - Phone:888-757-1951
Mailing Address - Fax:877-757-1951
Practice Address - Street 1:222 PHILADELPHIA PIKE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19809-3166
Practice Address - Country:US
Practice Address - Phone:888-757-1951
Practice Address - Fax:877-757-1951
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMT-0003800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist