Healthcare Provider Details

I. General information

NPI: 1154717544
Provider Name (Legal Business Name): JACLYN HESS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 DORNACH WAY
ADVANCE NC
27006-7305
US

IV. Provider business mailing address

2341 KINGS WAY
AUGUSTA GA
30904-4487
US

V. Phone/Fax

Practice location:
  • Phone: 336-940-2407
  • Fax:
Mailing address:
  • Phone: 336-909-0222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number8296
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number8296
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number210171
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2019-00260
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: