Provider Demographics
NPI:1154445534
Name:BAKER, JACQUELYNN DANIELLE (PA)
Entity Type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:DANIELLE
Last Name:BAKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JACQUELYNN
Other - Middle Name:DANIELLE
Other - Last Name:BERUMEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:619 E MASON ST
Mailing Address - Street 2:SUITE 4P57
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62701-1034
Mailing Address - Country:US
Mailing Address - Phone:217-788-0706
Mailing Address - Fax:217-525-2535
Practice Address - Street 1:619 E MASON ST
Practice Address - Street 2:SUITE 4P57
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1034
Practice Address - Country:US
Practice Address - Phone:217-788-0706
Practice Address - Fax:217-525-2535
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114211363A00000X
IL085004581363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S48241Medicare UPIN