Provider Demographics
NPI:1043776875
Name:NEBZYDOSKI, JACLYN VICTORIA
Entity type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:VICTORIA
Last Name:NEBZYDOSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JACLYN
Other - Middle Name:VICTORIA
Other - Last Name:GASSAWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PSC 455 BOX 208
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96540-0003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:US NAVAL HOSPITAL GUAM
Practice Address - Street 2:FARENHOLT AVE, BLDG 50
Practice Address - City:AGANA HEIGHTS
Practice Address - State:GU
Practice Address - Zip Code:96910
Practice Address - Country:US
Practice Address - Phone:671-344-9340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206234208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics