Provider Demographics
NPI:1922021070
Name:AGEE, JACKIE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNN
Last Name:AGEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 HOWE AVENUE., SUITE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825
Mailing Address - Country:US
Mailing Address - Phone:916-924-9337
Mailing Address - Fax:916-924-8281
Practice Address - Street 1:650 HOWE AVENUE,,SUITE 100
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825
Practice Address - Country:US
Practice Address - Phone:916-924-9337
Practice Address - Fax:916-924-8281
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37462208000000X
CAA47099208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
A47099Medicare UPIN