Provider Demographics
NPI:1164085023
Name:FORD, JACQUELINE ANN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN MARIE
Last Name:FORD
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 1:2082 PARIS LN
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:MO
Mailing Address - Zip Code:64865-8538
Mailing Address - Country:US
Mailing Address - Phone:417-389-6496
Mailing Address - Fax:
Practice Address - Street 1:100 MERCY WAY
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4524
Practice Address - Country:US
Practice Address - Phone:417-781-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2023003300207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program