Provider Demographics
NPI:1467107607
Name:VANCE, JACKIE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:VANCE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 MCCORMICK CV
Mailing Address - Street 2:
Mailing Address - City:HUTTO
Mailing Address - State:TX
Mailing Address - Zip Code:78634-2091
Mailing Address - Country:US
Mailing Address - Phone:847-525-5821
Mailing Address - Fax:
Practice Address - Street 1:1003 MCCORMICK CV
Practice Address - Street 2:
Practice Address - City:HUTTO
Practice Address - State:TX
Practice Address - Zip Code:78634-2091
Practice Address - Country:US
Practice Address - Phone:847-525-5821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-16
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2021185858207Q00000X
TX1071738363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine