Provider Demographics
NPI:1639156268
Name:BARNES, JACQUELYN KAY (PA)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:KAY
Last Name:BARNES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 PICKNEY RD
Mailing Address - Street 2:
Mailing Address - City:COPENHAGEN
Mailing Address - State:NY
Mailing Address - Zip Code:13626-3342
Mailing Address - Country:US
Mailing Address - Phone:907-406-9315
Mailing Address - Fax:
Practice Address - Street 1:1255 PICKNEY RD
Practice Address - Street 2:
Practice Address - City:COPENHAGEN
Practice Address - State:NY
Practice Address - Zip Code:13626-3342
Practice Address - Country:US
Practice Address - Phone:907-406-9315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004670363A00000X
NY023071363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1639156268OtherNPI
NY1639156268Medicaid