Jacqueline Nicole Perez, PA

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

4631 Issued in CT

Practice address

385 W Main St
Avon, CT 06001-4357

Phone

(860) 777-1280

NPI assigned

Oct 12, 2012

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Enrolled in CT

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Not enrolled

HHS exclusion list flag

Flagged The directory lists this NPI on an HHS exclusion list. The OIG exclusions file (LEIE) holds no record for this NPI, and the directory does not say which list the flag comes from. How exclusions are shown Confirm with the OIG exclusions search.

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: jacqueline.perez@chcict.eclinicaldirectplus.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Community Health Services, Inc.

  • Federally Qualified Health Center (FQHC)
  • Hartford, CT
  • NPI 1730284605
  Medicare reassignment
• Community Health Services, Inc.

  • Federally Qualified Health Center (FQHC)
  • Hartford, CT
  • NPI 1750632659
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1350000000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1588809600000",
    "number": "1407108558",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 44008",
            "address_2": "UFJAX - PROVIDER ENROLLMENT",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322314008",
            "telephone_number": "904-244-3199",
            "fax_number": "904-244-3425"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "385 W MAIN ST",
            "city": "AVON",
            "state": "CT",
            "postal_code": "060014357",
            "telephone_number": "860-777-1280"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "580 W 8th St",
            "address_2": "UFJAX - Dept. of Neurosurgery",
            "address_purpose": "LOCATION",
            "city": "Jacksonville",
            "state": "FL",
            "postal_code": "322096533",
            "country_code": "US",
            "telephone_number": "904-244-3950",
            "fax_number": "904-244-9437",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PEREZ",
        "first_name": "JACQUELINE",
        "middle_name": "NICOLE",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2012-10-12",
        "last_updated": "2020-05-07",
        "certification_date": "2020-05-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "WA",
            "license": "60363705",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "FL",
            "license": "PA9106924",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CT",
            "license": "4631",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CT LIC",
            "identifier": "004613",
            "state": "CT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "007207500",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003128788A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Emily Peck, LMFT
• Pediatric Dental Center of Avon, LLC
• Yolanda M Pena, MD
• Peoplesdental, P.C.
• Laura Kay Perednia, LCSW, LICSW
• Kenneth Perks, M.D.
• Tiffany T Perri, O.D.
• Kathryn Michelle Perrone, PT, DPT
• Sasha Perry, PMHNP
• Liliana Petrov

• Physician Assistant in Avon, CT
• Providers in Avon, CT by specialty
• Physician Assistant in Connecticut

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 7, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.