Provider Demographics
NPI:1447792478
Name:DAILEY, JAKE (FNP)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:DAILEY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 MEADOWS LN STE 1
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-9907
Mailing Address - Country:US
Mailing Address - Phone:912-537-9488
Mailing Address - Fax:912-537-8951
Practice Address - Street 1:1608 MEADOWS LN STE 1
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-9907
Practice Address - Country:US
Practice Address - Phone:912-537-9488
Practice Address - Fax:912-537-8951
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN208274363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily