Individual
JACQUELINE NICOLE PEREZ
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
385 W MAIN ST, AVON, CT 06001-4357
(860) 777-1280
Mailing address
PO BOX 44008, UFJAX - PROVIDER ENROLLMENT, JACKSONVILLE, FL 32231-4008
(904) 244-3199
(904) 244-3425
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
4631
CT
363A00000X
Physician Assistant
60363705
WA
363A00000X
Physician Assistant
PA9106924
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003128788A
—
GA
01
—
004613
CT LIC
CT
05
—
007207500
—
FL
Enumeration date
10/12/2012
Last updated
05/07/2020
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