Provider Demographics
NPI:1518989078
Name:DAVIS, JAQUELINE MARGARET (NP)
Entity Type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:MARGARET
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 E. 65TH STREET
Mailing Address - Street 2:SUITE 22
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405
Mailing Address - Country:US
Mailing Address - Phone:912-819-7878
Mailing Address - Fax:912-819-3555
Practice Address - Street 1:527 EISENHOWER DRIVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406
Practice Address - Country:US
Practice Address - Phone:912-819-9100
Practice Address - Fax:912-819-9101
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN143842363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA593466638AMedicaid
GA50BBLLGOtherOLD MEDICARE PTAN
GA01067491OtherAMERIGROUP
GA404178OtherWELLCARE
GAP00394154OtherRR MEDICARE
GA01067491OtherAMERIGROUP
GAQ78970Medicare UPIN
GA202I504289Medicare PIN