Provider Demographics
NPI:1225322126
Name:EDWARDS, JACQUELINE K (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:K
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1923 W MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53205-2035
Mailing Address - Country:US
Mailing Address - Phone:414-334-8625
Mailing Address - Fax:262-641-2300
Practice Address - Street 1:16505 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-5513
Practice Address - Country:US
Practice Address - Phone:262-641-2300
Practice Address - Fax:262-641-2311
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI2750-23363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical