Provider Demographics
NPI:1740657568
Name:EVERNHAM, JACQUELINE EMILY (PA-C)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:EMILY
Last Name:EVERNHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5000 LONG PRAIRIE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-2783
Mailing Address - Country:US
Mailing Address - Phone:972-420-1776
Mailing Address - Fax:972-221-8685
Practice Address - Street 1:5000 LONG PRAIRIE RD STE 100
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-2783
Practice Address - Country:US
Practice Address - Phone:972-420-1776
Practice Address - Fax:972-221-8685
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA079660363AS0400X
SD1014363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical