Provider Demographics
NPI:1144730615
Name:WOLK, JACQUELINE M (FNP)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:M
Last Name:WOLK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:MARIE
Other - Last Name:FLAVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 STE GENEVIEVE DR
Mailing Address - Street 2:
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-1434
Mailing Address - Country:US
Mailing Address - Phone:573-883-7781
Mailing Address - Fax:573-883-4411
Practice Address - Street 1:255 BODERMAN
Practice Address - Street 2:
Practice Address - City:BLOOMSDALE
Practice Address - State:MO
Practice Address - Zip Code:63627-9099
Practice Address - Country:US
Practice Address - Phone:573-483-2929
Practice Address - Fax:573-483-9612
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017036067363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily