Provider Demographics
NPI:1780950352
Name:YOUTSOS, JACQUELINE MARGARET (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MARGARET
Last Name:YOUTSOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:2425 BRADSHAW WAY
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-6600
Mailing Address - Country:US
Mailing Address - Phone:620-308-6123
Mailing Address - Fax:620-308-6264
Practice Address - Street 1:2425 BRADSHAW WAY
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-6600
Practice Address - Country:US
Practice Address - Phone:620-308-6123
Practice Address - Fax:620-308-6264
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0438483207Q00000X, 207N00000X
NMMD2012-0394207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201124850AMedicaid
KS201124850AMedicaid
OK200623870AMedicaid
NMNPI & TIN#OtherBCBS OF NM