Provider Demographics
NPI:1962824615
Name:BOONE, JACQUELINE (AGACNP-BC, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BOONE
Suffix:
Gender:F
Credentials:AGACNP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14321 WINTER BREEZE DR STE 67
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-2452
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3751 NINE MILE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-4830
Practice Address - Country:US
Practice Address - Phone:804-492-7263
Practice Address - Fax:804-220-5253
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2025-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013564363L00000X
VA0024175120363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner