Provider Demographics
NPI:1144504887
Name:WATERS, JACQUELINE DAYLE (PHARMD)
Entity type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:DAYLE
Last Name:WATERS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:DAYLE
Other - Last Name:DECICCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2251 E HANCOCK ST STE 100
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-2145
Mailing Address - Country:US
Mailing Address - Phone:971-281-3060
Mailing Address - Fax:971-281-3061
Practice Address - Street 1:2280 N LAS VEGAS BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-5803
Practice Address - Country:US
Practice Address - Phone:702-649-1415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2025-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0018868183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist