Provider Demographics
NPI:1609896497
Name:ADIELE, JACQUELENE MITCHELL (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELENE
Middle Name:MITCHELL
Last Name:ADIELE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 938
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76540-0938
Mailing Address - Country:US
Mailing Address - Phone:254-634-6999
Mailing Address - Fax:254-200-4099
Practice Address - Street 1:3816 S CLEAR CREEK RD
Practice Address - Street 2:SUITE A
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4400
Practice Address - Country:US
Practice Address - Phone:254-200-2748
Practice Address - Fax:254-200-2757
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2678207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX034049902Medicaid
1609896497OtherINDIVIDUAL NPI
TXTXB158053OtherMEDICARE
TXJ2678OtherTX MEDICAL BOARD LICENSE
TX034049902Medicaid
TXTXB158053OtherMEDICARE