Healthcare Provider Details

I. General information

NPI: 1891126827
Provider Name (Legal Business Name): JACQUELINE LECLERCQ CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 MERRIMAC CT
PRINCE FREDERICK MD
20678-6113
US

IV. Provider business mailing address

238 MERRIMAC COURT P O BOX 838
PRINCE FREDERICK MD
20678
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-0892
  • Fax: 410-535-5677
Mailing address:
  • Phone: 410-535-0892
  • Fax: 410-535-5677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR119066
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR1119066
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: