Provider Demographics
NPI:1134125230
Name:POWELL, JACQUELINE AUDREYMENIA (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:AUDREYMENIA
Last Name:POWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 41150
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85274
Mailing Address - Country:US
Mailing Address - Phone:480-425-2160
Mailing Address - Fax:480-351-8797
Practice Address - Street 1:2421 E SOUTHERN AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282
Practice Address - Country:US
Practice Address - Phone:480-425-2160
Practice Address - Fax:480-351-8797
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41012207L00000X
AZ47944207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000521683OtherANTHEM/BCBS
KY000000521683OtherANTHEM/BCBS
G47060Medicare UPIN
AZZ1669946Medicare PIN