Provider Demographics
NPI:1235775438
Name:EVANS, JACQUELINE M (PA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:EVANS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:2 SHIRCLIFF WAY STE 605
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4762
Mailing Address - Country:US
Mailing Address - Phone:904-328-5979
Mailing Address - Fax:904-619-9925
Practice Address - Street 1:631 PROFESSIONAL DR STE 170
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3392
Practice Address - Country:US
Practice Address - Phone:678-312-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-22
Last Update Date:2021-02-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA10160363AS0400X
FLPA9112791363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical