Individual
ROGER JACQUELIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
125 BUENA VISTA CIR, SOUTH HILL, VA 23970-1431
(952) 442-9770
Mailing address
400 E 10TH ST, WACONIA, MN 55387-4552
(952) 442-9770
(952) 442-3630
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
0001051476
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
080569
BLUE CROSS OF VA
VA
Enumeration date
11/17/2005
Last updated
04/28/2008
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