Provider Demographics
NPI:1013912930
Name:BEARDEN, JACQUELINE S (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:S
Last Name:BEARDEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5623 W 19TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-2901
Mailing Address - Country:US
Mailing Address - Phone:970-353-9011
Mailing Address - Fax:970-353-9135
Practice Address - Street 1:5623 W 19TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-2901
Practice Address - Country:US
Practice Address - Phone:970-353-9011
Practice Address - Fax:970-353-9135
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27516207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO72506717Medicaid
COE81973Medicare UPIN
CO72506717Medicaid
CO452728Medicare Oscar/Certification