Healthcare Provider Details

I. General information

NPI: 1700736162
Provider Name (Legal Business Name): JACQUANA SHANIECE PARKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2026
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 FITZGERALD RD
MONTGOMERY AL
36106-2628
US

IV. Provider business mailing address

3121 FITZGERALD RD
MONTGOMERY AL
36106-2628
US

V. Phone/Fax

Practice location:
  • Phone: 334-531-6506
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-166811
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: