1316991557 NPI number — MRS. JACQULYNE S BOOKER ANP

Table of content: MRS. JACQULYNE S BOOKER ANP (NPI 1316991557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316991557 NPI number — MRS. JACQULYNE S BOOKER ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOOKER
Provider First Name:
JACQULYNE
Provider Middle Name:
S
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ANP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316991557
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1329
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47402-1329
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-353-3087
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
995 S CLARIZZ BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47401-5588
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-353-3060
Provider Business Practice Location Address Fax Number:
812-353-3070
Provider Enumeration Date:
05/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  71001863 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 71001863 . This is a "INDIANA NURSE PRACTITIONE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 28085357A . This is a "INDIANA RN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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