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General NPI Number Information
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NPI Number | 1568071777
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Entity Type | Individual
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Provider Name | JACQUELINE H MODER
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Gender | Female
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Dates
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Enumeration Date | 07/24/2020
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Last Update Date | 07/24/2020
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Provider Practice Location Address
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Address Line | 1912 MEMORIAL DR STE E
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City | WAYCROSS
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State | GA
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Zip | 31501-0989
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Country | US
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Telephone | 912-283-7100
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Fax |
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Provider Business Mailing Address
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Address Line | 6115 COTTONWOOD LN
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City | BLACKSHEAR
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State | GA
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Zip | 31516-5992
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Country | US
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Telephone | 912-286-4400
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 11006710
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | RN240089
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License Number State | GA
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