Healthcare Provider Details

I. General information

NPI: 1447586086
Provider Name (Legal Business Name): REBECCA JILL BRACKETT FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2009
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST
MACON GA
31201-2102
US

IV. Provider business mailing address

2490 RIVERSIDE DR STE B
MACON GA
31204-1787
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-1000
  • Fax:
Mailing address:
  • Phone: 478-633-6644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5004991
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4041
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number195045
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: