Healthcare Provider Details

I. General information

NPI: 1801880497
Provider Name (Legal Business Name): JACQUELYN ELAINE ROBERTS ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: JACQUELYN ELAINE SHADDIX

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 31ST AVE SE
MOULTRIE GA
31768-6771
US

IV. Provider business mailing address

115 31ST AVE SE
MOULTRIE GA
31768-6771
US

V. Phone/Fax

Practice location:
  • Phone: 229-890-1665
  • Fax: 229-985-5050
Mailing address:
  • Phone: 229-890-1665
  • Fax: 229-985-5050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberRN128424
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: