Provider Demographics
NPI:1609180645
Name:DEYOUNGE-GERIDEAU, JACQUELINE EUDORA (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:EUDORA
Last Name:DEYOUNGE-GERIDEAU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2455 ROBINSON RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-3852
Mailing Address - Country:US
Mailing Address - Phone:972-522-5665
Mailing Address - Fax:972-522-5605
Practice Address - Street 1:2455 ROBINSON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-3852
Practice Address - Country:US
Practice Address - Phone:972-522-5665
Practice Address - Fax:972-522-5605
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01588363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant