Provider Demographics
NPI:1134200991
Name:BALCH, JACQUALINE RAE (RN, APRN)
Entity type:Individual
Prefix:MS
First Name:JACQUALINE
Middle Name:RAE
Last Name:BALCH
Suffix:
Gender:F
Credentials:RN, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6104 AVENUE Q SOUTH DR
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79412-3700
Mailing Address - Country:US
Mailing Address - Phone:806-472-3430
Mailing Address - Fax:806-472-3432
Practice Address - Street 1:6104 AVENUE Q SOUTH DR
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79412-3700
Practice Address - Country:US
Practice Address - Phone:806-472-3430
Practice Address - Fax:806-472-3432
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX446047363LF0000X
TX440647363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXVAD000Medicare UPIN