Provider Demographics
NPI:1710909981
Name:TETREAULT, JACQUELINE ANN (M,D,)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:TETREAULT
Suffix:
Gender:F
Credentials:M,D,
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:ANN
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3815 S. VAL VISTA DRIVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7309
Mailing Address - Country:US
Mailing Address - Phone:480-782-0993
Mailing Address - Fax:855-329-8939
Practice Address - Street 1:3815 S. VAL VISTA DRIVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7309
Practice Address - Country:US
Practice Address - Phone:480-782-0993
Practice Address - Fax:855-329-8939
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD7783207V00000X
AZ44743207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00700784Medicare UPIN