Provider Demographics
NPI:1124189600
Name:GRANT, JACQUELINE H (MD, MPH, MPA)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:H
Last Name:GRANT
Suffix:
Gender:F
Credentials:MD, MPH, MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNC DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
Mailing Address - Street 2:3010 OLD CLINIC BUILDING CB # 7516
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27599-7516
Mailing Address - Country:US
Mailing Address - Phone:919-966-6444
Mailing Address - Fax:919-966-6377
Practice Address - Street 1:2000 10TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3703
Practice Address - Country:US
Practice Address - Phone:706-571-1285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-00684207VM0101X
GA032570207VM0101X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA695415663AMedicaid
GA695415663AMedicaid
GABG3220869OtherDEA REGISTRATION #
GAF21831Medicare UPIN