Provider Demographics
NPI:1528185568
Name:DONNELLY, JACQUELYN (ACNP)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2714 UNION AVENUE EXT
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-4431
Mailing Address - Country:US
Mailing Address - Phone:901-725-0872
Mailing Address - Fax:901-278-6934
Practice Address - Street 1:2714 UNION AVENUE EXT
Practice Address - Street 2:SUITE 150
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-4431
Practice Address - Country:US
Practice Address - Phone:901-725-0872
Practice Address - Fax:901-278-6934
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10658364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10350I6318OtherMEDICARE PTAN
TN1512704Medicaid
TN4321835OtherBCBST