Provider Demographics
NPI:1568606309
Name:PELLETIER, JACQUELINE ELIZABETH (PNP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ELIZABETH
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5348 COLE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-1119
Mailing Address - Country:US
Mailing Address - Phone:619-723-1141
Mailing Address - Fax:
Practice Address - Street 1:3020 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4223
Practice Address - Country:US
Practice Address - Phone:858-966-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15739363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics