Provider Demographics
NPI:1851378871
Name:EVANS, JACQUELINE ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ANN
Last Name:EVANS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 S 2ND ST STE 2F
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:717-874-4297
Mailing Address - Fax:717-874-4298
Practice Address - Street 1:2150 NOLL DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603
Practice Address - Country:US
Practice Address - Phone:717-874-4297
Practice Address - Fax:717-874-4298
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008644L207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001726636Medicaid
PA0017266360008Medicaid
PA064209Medicare ID - Type Unspecified