Provider Demographics
NPI:1962824615
Name:BOONE, JACQUELINE (MSN, AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BOONE
Suffix:
Gender:F
Credentials:MSN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4992
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-0017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5875 BREMO RD STE 400
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1928
Practice Address - Country:US
Practice Address - Phone:804-287-3550
Practice Address - Fax:804-281-7840
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024175120363L00000X
PASP013564363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner