Provider Demographics
NPI:1154060028
Name:PARKS, JACQUELINE PHYLLIS (RN)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:PHYLLIS
Last Name:PARKS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 COUNTY ROAD 8
Mailing Address - Street 2:
Mailing Address - City:CORUNNA
Mailing Address - State:IN
Mailing Address - Zip Code:46730-9756
Mailing Address - Country:US
Mailing Address - Phone:260-318-1046
Mailing Address - Fax:
Practice Address - Street 1:2121 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5100
Practice Address - Country:US
Practice Address - Phone:260-426-5431
Practice Address - Fax:260-421-1092
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28179527A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse