Provider Demographics
NPI:1033216650
Name:BORN, JACQUELINE (CNM)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BORN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 NATIONWIDE DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-4271
Mailing Address - Country:US
Mailing Address - Phone:434-239-7890
Mailing Address - Fax:434-237-9222
Practice Address - Street 1:114 NATIONWIDE DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-4271
Practice Address - Country:US
Practice Address - Phone:434-237-9233
Practice Address - Fax:434-237-9222
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA367A00000X
VA024055675363LX0001X
NC83645367A00000X
SC3761367A00000X
KY2054M367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC372048Medicaid
000000198919OtherBCBS PROVIDER NUMBER
SCCBP031Medicaid
KY2054MOtherLICENSE
NC70022511Medicaid
KY78000908Medicaid
0691621Medicare PIN
0935336Medicare PIN
SC7124Medicare PIN
0374573Medicare PIN