Healthcare Provider Details

I. General information

NPI: 1063482339
Provider Name (Legal Business Name): JACQUELINE SPAIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 MAPLE ST
HOLYOKE MA
01040-5124
US

IV. Provider business mailing address

PO BOX 6260 230 MAPLE ST
HOLYOKE MA
01041-6260
US

V. Phone/Fax

Practice location:
  • Phone: 413-420-2200
  • Fax: 413-420-2260
Mailing address:
  • Phone: 413-420-2200
  • Fax: 413-420-2260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number77663
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: