Provider Demographics
NPI:1477853539
Name:BAKER, JACQUELINE R (PA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:R
Last Name:BAKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15225
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61132-5225
Mailing Address - Country:US
Mailing Address - Phone:815-713-2600
Mailing Address - Fax:815-654-8020
Practice Address - Street 1:4328 ARMOUR RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-5204
Practice Address - Country:US
Practice Address - Phone:706-507-1213
Practice Address - Fax:706-507-1217
Is Sole Proprietor?:No
Enumeration Date:2010-10-23
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5954363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1699976332OtherGROUP NPI
GA4759OtherGROUP