Provider Demographics
NPI:1588755441
Name:EVANS, JACQUELINE MERYL (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MERYL
Last Name:EVANS
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 1:6004 MANOR PARK TER
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5496
Mailing Address - Country:US
Mailing Address - Phone:916-397-5585
Mailing Address - Fax:
Practice Address - Street 1:5801 BREMO RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1907
Practice Address - Country:US
Practice Address - Phone:916-397-5585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2022-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87264207RC0200X
IAMD-445962080P0203X
VA01012663782080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G872640Medicaid
CA00G872640Medicaid
CAWG87264AMedicare ID - Type Unspecified