Healthcare Provider Details

I. General information

NPI: 1235775438
Provider Name (Legal Business Name): JACQUELINE M RICE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2019
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 PROFESSIONAL DR STE 170
LAWRENCEVILLE GA
30046-3392
US

IV. Provider business mailing address

1973 BOYD TRACE LN NW
ATLANTA GA
30318-4471
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-2663
  • Fax:
Mailing address:
  • Phone: 859-684-5250
  • Fax: 859-684-5250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9112791
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10160
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: