MEDICARE: MRS. JACQUELYN H WELLS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CSW000434	GA

General Provider Information

NPI Number	:	1215983010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JACQUELYN H WELLS LCSW

Provider Business Mailing Address
First Line	:	AUGUSTA VA MEDICAL CENTER
Second Line	:	WRIGHTSBORO ROAD
City	:	AUGUSTA
State	:	GA
Zip	:	30904-6285
Country	:	US
Telephone Number	:	706-733-0188
Fax Number	:

Provider Business Practice Location Address
First Line	:	923 W WOODLAWN AVE
Second Line	:
City	:	NORTH AUGUSTA
State	:	SC
Zip	:	29841-3214
Country	:	US
Telephone Number	:	803-279-6665
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	07/08/2007

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