Healthcare Provider Details

I. General information

NPI: 1851084321
Provider Name (Legal Business Name): JACQUELINE EVETT LAWRENCE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 REGENT ST STE 200
COLUMBUS OH
43219-6229
US

IV. Provider business mailing address

903 69TH CT
MERIDIAN MS
39305-8100
US

V. Phone/Fax

Practice location:
  • Phone: 877-870-1775
  • Fax: 614-968-8840
Mailing address:
  • Phone: 304-516-3930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF05230722
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95032706
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number906899
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024187405
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: