Provider Demographics
NPI:1174688949
Name:DENNIS, JACKIE G (RN)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:G
Last Name:DENNIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 ELKTON RD
Mailing Address - Street 2:
Mailing Address - City:CLARKTON
Mailing Address - State:NC
Mailing Address - Zip Code:28433-8747
Mailing Address - Country:US
Mailing Address - Phone:910-645-4933
Mailing Address - Fax:
Practice Address - Street 1:300 MERCER MILL RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337
Practice Address - Country:US
Practice Address - Phone:910-862-6900
Practice Address - Fax:910-872-6290
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC139366163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse