Healthcare Provider Details

I. General information

NPI: 1053648337
Provider Name (Legal Business Name): MRS. JACQULINE JEFFREY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2009
Last Update Date: 11/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 WALTON WAY
AUGUSTA GA
30901-2612
US

IV. Provider business mailing address

1350 WALTON WAY
AUGUSTA GA
30901-2612
US

V. Phone/Fax

Practice location:
  • Phone: 706-722-9011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279C0205X
TaxonomyCritical Care Registered Respiratory Therapist
License Number006980
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: