Healthcare Provider Details

I. General information

NPI: 1114203676
Provider Name (Legal Business Name): JACQUELINE WAICE DC, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2011
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5064 ROSWELL RD SUITE C-201
ATLANTA GA
30342-2281
US

IV. Provider business mailing address

1627 WINDSTONE DR
RINGGOLD GA
30736-4123
US

V. Phone/Fax

Practice location:
  • Phone: 404-233-2440
  • Fax:
Mailing address:
  • Phone: 570-956-1956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCHIR008886
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: