Provider Demographics
NPI:1396085981
Name:O'KANE, JACQUELINE MICHELE (DO)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MICHELE
Last Name:O'KANE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:MICHELE
Other - Last Name:PILCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15125 US HIGHWAY 19 S
Mailing Address - Street 2:PMB 381
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792
Mailing Address - Country:US
Mailing Address - Phone:229-466-2009
Mailing Address - Fax:229-210-9044
Practice Address - Street 1:3358 NORTON PL
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-6591
Practice Address - Country:US
Practice Address - Phone:229-466-2009
Practice Address - Fax:229-210-9044
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-19
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3324207Q00000X
GA85496207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC357027Medicaid
SC357027Medicaid