Healthcare Provider Details

I. General information

NPI: 1063124956
Provider Name (Legal Business Name): JACQUELINE VICTORIA DUGAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2022
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W LINCOLN AVE
AVA MO
65608-5567
US

IV. Provider business mailing address

1674 FOLLY RD APT 108
CHARLESTON SC
29412-8701
US

V. Phone/Fax

Practice location:
  • Phone: 417-683-6790
  • Fax: 417-683-6770
Mailing address:
  • Phone: 417-299-3550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2024042522
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: