Provider Demographics
NPI:1225694102
Name:SMALL, JACQUELYN GERALDINE (DO)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:GERALDINE
Last Name:SMALL
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3909 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1725
Practice Address - Country:US
Practice Address - Phone:260-469-6610
Practice Address - Fax:260-969-3065
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101025847207Q00000X
IN02007766A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine