Basic Information
| Provider Information | |||||||||
| NPI: | 1407108558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | UFJAX - PROVIDER ENROLLMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443199 | ||||||||
| FaxNumber: | 9042443425 | ||||||||
| Practice Location | |||||||||
| Address1: | 385 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060014357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607771280 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2012 | ||||||||
| LastUpdateDate: | 05/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 60363705 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA9106924 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 4631 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 004613 | 01 | CT | CT LIC | OTHER | 007207500 | 05 | FL | MEDICAID | 003128788A | 05 | GA | MEDICAID |