Provider Demographics
NPI:1427437151
Name:GUTIERREZ, JACQUELINE (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 3RD ST W BLDG 1040
Mailing Address - Street 2:
Mailing Address - City:JBSA RANDOLPH
Mailing Address - State:TX
Mailing Address - Zip Code:78150-4800
Mailing Address - Country:US
Mailing Address - Phone:210-652-4267
Mailing Address - Fax:
Practice Address - Street 1:221 3RD ST W BLDG 1040
Practice Address - Street 2:
Practice Address - City:JBSA RANDOLPH
Practice Address - State:TX
Practice Address - Zip Code:78150-4800
Practice Address - Country:US
Practice Address - Phone:210-652-4267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-27
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NE30128171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program