Provider Demographics
NPI:1073790218
Name:BETTS, JACQUELINE DENISE
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:DENISE
Last Name:BETTS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:DENISE
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 DICKERSON DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-3826
Mailing Address - Country:US
Mailing Address - Phone:912-538-8474
Mailing Address - Fax:
Practice Address - Street 1:415 DICKERSON DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-3826
Practice Address - Country:US
Practice Address - Phone:912-538-8474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN059040164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA16OtherNURSING