Provider Demographics
NPI:1306076435
Name:SKRUTVOLD, JACQUELINE KRISTINNA (PA)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:KRISTINNA
Last Name:SKRUTVOLD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 910221 PO
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-3526
Mailing Address - Country:US
Mailing Address - Phone:520-519-7700
Mailing Address - Fax:
Practice Address - Street 1:603 N WILMOT RD # 151
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2701
Practice Address - Country:US
Practice Address - Phone:520-886-0206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ444363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant