Provider Demographics
NPI:1477676500
Name:MCMILLIAN, JACQUELINE
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:MCMILLIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26102
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5018
Mailing Address - Country:US
Mailing Address - Phone:910-583-4172
Mailing Address - Fax:
Practice Address - Street 1:5302 SLATER AVE.
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301
Practice Address - Country:US
Practice Address - Phone:910-488-6130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7805049320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities