Provider Demographics
NPI:1659027738
Name:YATES, JACQUEISE
Entity Type:Individual
Prefix:
First Name:JACQUEISE
Middle Name:
Last Name:YATES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUE
Other - Middle Name:
Other - Last Name:YATES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1103 SUSSEX DR
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-6535
Mailing Address - Country:US
Mailing Address - Phone:219-577-6073
Mailing Address - Fax:
Practice Address - Street 1:1103 SUSSEX DR
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-6535
Practice Address - Country:US
Practice Address - Phone:219-577-6073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-26
Last Update Date:2022-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula