Provider Demographics
NPI:1013194695
Name:JACQUELINE G. HANCOCK, CRNA, PA
Entity Type:Organization
Organization Name:JACQUELINE G. HANCOCK, CRNA, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE ANESTHETIST
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:GWEN
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:410-893-1172
Mailing Address - Street 1:3245 FARM LN
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MD
Mailing Address - Zip Code:21102-1780
Mailing Address - Country:US
Mailing Address - Phone:410-893-1172
Mailing Address - Fax:410-893-5806
Practice Address - Street 1:686 B POOLE ROAD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MARYLAND
Practice Address - Zip Code:21157
Practice Address - Country:AF
Practice Address - Phone:410-848-2203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-26
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR036423261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDNN40JGOtherBCBS
MD=========OtherTRICARE
MDNN40JGOtherBCBS