Provider Demographics
NPI:1518939230
Name:YATES, JACQUELINE F (DO)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:F
Last Name:YATES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:FAYE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:821 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-2102
Mailing Address - Country:US
Mailing Address - Phone:660-826-4774
Mailing Address - Fax:660-826-1300
Practice Address - Street 1:510 FOSTER LN STE 201
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-3239
Practice Address - Country:US
Practice Address - Phone:602-627-4156
Practice Address - Fax:660-262-7416
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004025543208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
I27306Medicare UPIN