Provider Demographics
NPI:1548477433
Name:BAKER, JACQUELINE (APRN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 MAIN STREET 2ND FLOOR
Mailing Address - Street 2:ATTN; CREDENTIALING DEPT
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457
Mailing Address - Country:US
Mailing Address - Phone:860-347-6971
Mailing Address - Fax:
Practice Address - Street 1:134 STATE ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-3293
Practice Address - Country:US
Practice Address - Phone:203-237-2229
Practice Address - Fax:203-686-1677
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002812363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235900Medicaid
CT004236346Medicaid