Healthcare Provider Details

I. General information

NPI: 1407108558
Provider Name (Legal Business Name): JACQUELINE NICOLE PEREZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2012
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 W MAIN ST
AVON CT
06001-4357
US

IV. Provider business mailing address

PO BOX 44008 UFJAX - PROVIDER ENROLLMENT
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 860-777-1280
  • Fax:
Mailing address:
  • Phone: 904-244-3199
  • Fax: 904-244-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number60363705
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9106924
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4631
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: