=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477145779
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE MARIE SCOTT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2021
-----------------------------------------------------
Last Update Date | 02/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3535 CHERE CAROL RD
-----------------------------------------------------
City | HUMBOLDT
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38343-3634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-513-5701
-----------------------------------------------------
Fax | 877-670-6150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3535 CHERE CAROL RD
-----------------------------------------------------
City | HUMBOLDT
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38343-3634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-513-5701
-----------------------------------------------------
Fax | 877-670-6150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 28946
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------