Provider Demographics
NPI:1386740215
Name:SQUIRES, JACKIE DONCEEL (CNM)
Entity type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:DONCEEL
Last Name:SQUIRES
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9501 W WOLF MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:GOSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47433-9597
Mailing Address - Country:US
Mailing Address - Phone:812-876-4151
Mailing Address - Fax:
Practice Address - Street 1:338 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-3500
Practice Address - Country:US
Practice Address - Phone:812-349-7343
Practice Address - Fax:812-349-7346
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN72000030367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife