Provider Demographics
NPI:1306106687
Name:JACQUELENE MITCHELL ADIELE, MD, PA
Entity type:Organization
Organization Name:JACQUELENE MITCHELL ADIELE, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELENE
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:ADIELE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-371-1172
Mailing Address - Street 1:PO BOX 938
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76540-0938
Mailing Address - Country:US
Mailing Address - Phone:254-634-6999
Mailing Address - Fax:254-200-4099
Practice Address - Street 1:3816 S CLEAR CREEK RD
Practice Address - Street 2:SUITE A
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4400
Practice Address - Country:US
Practice Address - Phone:254-200-2748
Practice Address - Fax:254-200-2757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-21
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2678207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1609896497OtherNPI (INDIVIDUAL)
TX034049902OtherMEDICAID (INDIVIDUAL)
TX306297801OtherMEDICAID (GROUP)
TXTXB158052OtherMEDICARE (GROUP)
1306106687OtherNPI (GROUP)
TXTXB158053OtherMEDICARE (INDIVIDUAL)
TXF35287Medicare UPIN