Provider Demographics
NPI:1043350812
Name:BANDY, JACQUELINE WHITAKER
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:WHITAKER
Last Name:BANDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 FAIRWAY TER
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-9618
Mailing Address - Country:US
Mailing Address - Phone:252-443-4276
Mailing Address - Fax:252-443-4014
Practice Address - Street 1:3072 SUNSET AVE # B
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-3647
Practice Address - Country:US
Practice Address - Phone:252-443-4276
Practice Address - Fax:252-443-4014
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3572251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601597Medicaid