Healthcare Provider Details

I. General information

NPI: 1528444080
Provider Name (Legal Business Name): JACY KILLIAN CROCKER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 FERNDALE BLVD
HIGH POINT NC
27262-4739
US

IV. Provider business mailing address

100 KIMEL FOREST DR
WINSTON SALEM NC
27103-6074
US

V. Phone/Fax

Practice location:
  • Phone: 336-882-2567
  • Fax: 336-882-2567
Mailing address:
  • Phone: 336-713-0947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number230341
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number108810
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: