Provider Demographics
NPI:1104689793
Name:FUNK, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FUNK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8230 WALNUT HILL BUILDING 3 SUITE 320
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231
Mailing Address - Country:US
Mailing Address - Phone:214-369-5432
Mailing Address - Fax:214-369-5591
Practice Address - Street 1:8230 WALNUT HILL BUILDING 3 SUITE 320
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231
Practice Address - Country:US
Practice Address - Phone:214-369-5432
Practice Address - Fax:214-369-5591
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-06-09
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical