Provider Demographics
NPI:1316991557
Name:BOOKER, JACQULYNE S (ANP)
Entity type:Individual
Prefix:MRS
First Name:JACQULYNE
Middle Name:S
Last Name:BOOKER
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1329
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-1329
Mailing Address - Country:US
Mailing Address - Phone:812-353-3087
Mailing Address - Fax:
Practice Address - Street 1:995 S CLARIZZ BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5588
Practice Address - Country:US
Practice Address - Phone:812-353-3060
Practice Address - Fax:812-353-3070
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001863363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71001863OtherINDIANA NURSE PRACTITIONE
IN28085357AOtherINDIANA RN