Provider Demographics
NPI:1063482339
Name:SPAIN, JACQUELINE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:SPAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6260
Mailing Address - Street 2:230 MAPLE ST
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01041-6260
Mailing Address - Country:US
Mailing Address - Phone:413-420-2200
Mailing Address - Fax:413-420-2260
Practice Address - Street 1:230 MAPLE ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-5124
Practice Address - Country:US
Practice Address - Phone:413-420-2200
Practice Address - Fax:413-420-2260
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA77663208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA8339OtherBOSTON HEALTH NET
MA0010026OtherNEIGHBORHOOD HEALTH PLAN
MA976243OtherNETWORK HEALTH
MASPJ18312OtherBLUE CROSS BLUE SHIELD
MA976243OtherNETWORK HEALTH