Provider Demographics
NPI:1407108558
Name:PEREZ, JACQUELINE NICOLE (PA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:PA
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 44008
Mailing Address - Street 2:UFJAX - PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:385 W MAIN ST
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-4357
Practice Address - Country:US
Practice Address - Phone:860-777-1280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60363705363A00000X
FLPA9106924363A00000X
CT4631363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004613OtherCT LIC
FL007207500Medicaid
GA003128788AMedicaid