Healthcare Provider Details

I. General information

NPI: 1659826808
Provider Name (Legal Business Name): JACQUELINE BACA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2016
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVENUE LAKESIDE BUILDING SUITE 6223
CLEVELAND OH
44106
US

IV. Provider business mailing address

11100 EUCLID AVENUE LAKESIDE BUILDING SUITE 6223
CLEVELAND OH
44106
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-3887
  • Fax:
Mailing address:
  • Phone: 216-844-3887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.147607
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: