Provider Demographics
NPI:1609069566
Name:JAMES, JACQUELINE J (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:J
Last Name:JAMES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:J
Other - Last Name:WINNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3000 OLD CENTRE ROAD
Mailing Address - Street 2:SOUTHWEST MICHIGAN DERMATOLOGY, A DIVISION OF PARAGON H
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024
Mailing Address - Country:US
Mailing Address - Phone:269-321-7546
Mailing Address - Fax:269-321-1705
Practice Address - Street 1:3000 OLD CENTRE ROAD
Practice Address - Street 2:SOUTHWEST MICHIGAN DERMATOLOGY, A DIVISION OF PARAGON H
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-321-7546
Practice Address - Fax:269-321-1705
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
MI5601005156363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1609069566Medicaid
MI1609069566Medicaid
MI160C976180OtherBCBSM