Provider Demographics
NPI:1407236474
Name:WRIGHT, JACQUELINE NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:WRIGHT
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 1:1500 CAMDEN AVE APT 3A
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3441
Mailing Address - Country:US
Mailing Address - Phone:918-261-6938
Mailing Address - Fax:844-797-8610
Practice Address - Street 1:1301 N COLUMBIA RD
Practice Address - Street 2:RM E280, STOP 9037
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203
Practice Address - Country:US
Practice Address - Phone:701-777-3067
Practice Address - Fax:701-777-2609
Is Sole Proprietor?:No
Enumeration Date:2015-06-04
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA150761208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery