Healthcare Provider Details

I. General information

NPI: 1285390344
Provider Name (Legal Business Name): JACQUELINE BAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2021
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 HILL TOP CIR
GRANTVILLE GA
30220-2076
US

IV. Provider business mailing address

23 HILL TOP CIR
GRANTVILLE GA
30220-2076
US

V. Phone/Fax

Practice location:
  • Phone: 765-969-1616
  • Fax:
Mailing address:
  • Phone: 765-969-1616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA001688
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: