Provider Demographics
NPI:1003160276
Name:KING, JACQUELINE YVONNE
Entity Type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:YVONNE
Last Name:KING
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 1:7212 ISHERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-2119
Mailing Address - Country:US
Mailing Address - Phone:901-644-8682
Mailing Address - Fax:
Practice Address - Street 1:7212 ISHERWOOD RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-2119
Practice Address - Country:US
Practice Address - Phone:901-644-8682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-09
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN86654164172A00000X, 343900000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No172A00000XOther Service ProvidersDriver
No347C00000XTransportation ServicesPrivate Vehicle