Provider Demographics
NPI:1891945424
Name:PAUL, JACQUELYNN PATRICE (MS)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYNN
Middle Name:PATRICE
Last Name:PAUL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 984
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85299-0984
Mailing Address - Country:US
Mailing Address - Phone:480-507-5004
Mailing Address - Fax:480-507-5007
Practice Address - Street 1:1121 E MISSOURI AVE STE 122
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2723
Practice Address - Country:US
Practice Address - Phone:602-277-3535
Practice Address - Fax:480-507-5007
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor