Provider Demographics
NPI:1942290283
Name:KROHN, JACQUELINE ANNE (MD MPH)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ANNE
Last Name:KROHN
Suffix:
Gender:F
Credentials:MD MPH
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3917 WEST RD
Mailing Address - Street 2:SUITE 136
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2275
Mailing Address - Country:US
Mailing Address - Phone:505-662-9620
Mailing Address - Fax:505-662-0024
Practice Address - Street 1:3917 WEST RD
Practice Address - Street 2:SUITE 136
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-2275
Practice Address - Country:US
Practice Address - Phone:505-662-9620
Practice Address - Fax:505-662-0024
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM79195208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11783Medicaid
D35764Medicare UPIN