Healthcare Provider Details

I. General information

NPI: 1245500644
Provider Name (Legal Business Name): JACLYN NICOLE HALL NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST BIW6033
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1120 15TH ST BIW6033
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-2331
  • Fax: 706-721-7531
Mailing address:
  • Phone: 706-721-2331
  • Fax: 706-721-7531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License NumberRN189087
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: