Provider Demographics
NPI:1962491845
Name:OLMERT, JACQUELINE A (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:OLMERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:OLMERT
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 33269
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-3269
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:500 W THOMAS RD STE 900A
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4223
Practice Address - Country:US
Practice Address - Phone:602-406-3540
Practice Address - Fax:602-406-7186
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27776207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ479114Medicaid
AZ28172Medicare ID - Type Unspecified