Provider Demographics
NPI:1225271737
Name:STEWART, JACQUELYN M (ACNP)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:M
Last Name:STEWART
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 GLYNN ST S
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-2049
Mailing Address - Country:US
Mailing Address - Phone:770-719-5490
Mailing Address - Fax:770-719-3113
Practice Address - Street 1:745 GLYNN ST S
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2049
Practice Address - Country:US
Practice Address - Phone:770-719-5490
Practice Address - Fax:770-719-3113
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN111294-NP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care