Provider Demographics
NPI:1407290596
Name:CRAFT, JACKIE LYNNE (ANP)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNNE
Last Name:CRAFT
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:373 CECIL D QUILLEN DR STE 101
Mailing Address - Street 2:REGIONAL HEALTH RESOURCES
Mailing Address - City:DUFFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24244-4085
Mailing Address - Country:US
Mailing Address - Phone:276-431-1638
Mailing Address - Fax:
Practice Address - Street 1:373 CECIL D QUILLEN DR STE 101
Practice Address - Street 2:373 CECIL D. QUILLEN DRIVE SUITE 101
Practice Address - City:DUFFIELD
Practice Address - State:VA
Practice Address - Zip Code:24244-4085
Practice Address - Country:US
Practice Address - Phone:276-431-1638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170808363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health