Provider Demographics
NPI:1245521749
Name:BAE, JACQUELINE J (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:J
Last Name:BAE
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:PO BOX 1558
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-1558
Mailing Address - Country:US
Mailing Address - Phone:213-663-2538
Mailing Address - Fax:
Practice Address - Street 1:925 BEVINS CT
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-9754
Practice Address - Country:US
Practice Address - Phone:707-263-8382
Practice Address - Fax:707-263-0329
Is Sole Proprietor?:No
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No101Y00000XBehavioral Health & Social Service ProvidersCounselor