Provider Demographics
NPI:1083381115
Name:DAVIDSON, JACQUELINE ANN (REGISTERD NURSE)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:REGISTERD NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14209 SHOOTING STAR DR
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-4630
Mailing Address - Country:US
Mailing Address - Phone:217-251-1676
Mailing Address - Fax:
Practice Address - Street 1:14209 SHOOTING STAR DR
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-4630
Practice Address - Country:US
Practice Address - Phone:217-251-1676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28165106A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse