Provider Demographics
NPI:1295285773
Name:EDWARDS, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
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 3071
Mailing Address - Street 2:
Mailing Address - City:LANDERS
Mailing Address - State:CA
Mailing Address - Zip Code:92285-0071
Mailing Address - Country:US
Mailing Address - Phone:484-347-3939
Mailing Address - Fax:
Practice Address - Street 1:57402 TWENTYNINE PALMS HIGHWAY #1
Practice Address - Street 2:SUITE 1
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-9228
Practice Address - Country:US
Practice Address - Phone:760-365-2520
Practice Address - Fax:484-526-6546
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058708363A00000X
CA58432363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant