Provider Demographics
NPI:1942559703
Name:MILLS, JACQUELINE (JACQUELINE MILLS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MILLS
Suffix:
Gender:F
Credentials:JACQUELINE MILLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 C ST W BLDG 492
Mailing Address - Street 2:
Mailing Address - City:JBSA RANDOLPH
Mailing Address - State:TX
Mailing Address - Zip Code:78150-4702
Mailing Address - Country:US
Mailing Address - Phone:210-322-0105
Mailing Address - Fax:
Practice Address - Street 1:550 C ST W BLDG 492
Practice Address - Street 2:
Practice Address - City:JBSA RANDOLPH
Practice Address - State:TX
Practice Address - Zip Code:78150-4702
Practice Address - Country:US
Practice Address - Phone:210-322-0105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant