Provider Demographics
NPI:1821697590
Name:BARAJAS, JACQUELINE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BARAJAS
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 E PARKCENTER BLVD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6528
Practice Address - Country:US
Practice Address - Phone:208-381-6500
Practice Address - Fax:208-381-6505
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2022-0084363A00000X
NMPA2022-0084363A00000X
NMPA2022-084363AM0700X
IDPA-2751363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical