Basic Information
Provider Information | |||||||||
NPI: | 1154609162 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BASKIN-MILLER | ||||||||
FirstName: | JACQUELYN | ||||||||
MiddleName: | LISA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 170 MANNING DR CAMPUS BOX 7236 | ||||||||
Address2: |   | ||||||||
City: | CHAPEL HILL | ||||||||
State: | NC | ||||||||
PostalCode: | 275997236 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9199661178 | ||||||||
FaxNumber: | 9199667629 | ||||||||
Practice Location | |||||||||
Address1: | 4650 W SUNSET BLVD | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900276062 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3233613550 | ||||||||
FaxNumber: | 3233618052 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2011 | ||||||||
LastUpdateDate: | 08/13/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0207X | A104511 | CA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
No ID Information.