Provider Demographics
NPI:1649289075
Name:DOYLE, JACQUELINE JESSICA (PA-C)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:JESSICA
Last Name:DOYLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:J
Other - Last Name:DOYLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:804 DON GASPAR AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-2632
Mailing Address - Country:US
Mailing Address - Phone:505-577-0369
Mailing Address - Fax:
Practice Address - Street 1:1422 PASEO DE PERALTA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-4391
Practice Address - Country:US
Practice Address - Phone:505-577-0369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM82-PA005363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMS77364Medicare UPIN