Provider Demographics
NPI:1376313932
Name:O'DOHERTY, JACQUELINE G (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:G
Last Name:O'DOHERTY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 PINE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-3389
Mailing Address - Country:US
Mailing Address - Phone:402-489-8888
Mailing Address - Fax:402-421-1945
Practice Address - Street 1:5500 PINE LAKE RD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-3389
Practice Address - Country:US
Practice Address - Phone:402-489-8888
Practice Address - Fax:402-421-1945
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3062363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant