Basic Information
| Provider Information | |||||||||
| NPI: | 1710909981 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TETREAULT | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M,D, | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PERRY | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3815 S. VAL VISTA DRIVE | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852977309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807820993 | ||||||||
| FaxNumber: | 8553298939 | ||||||||
| Practice Location | |||||||||
| Address1: | 3815 S. VAL VISTA DRIVE | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852977309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807820993 | ||||||||
| FaxNumber: | 8553298939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 12/22/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD7783 | RI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 44743 | AZ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.