Provider Demographics
NPI:1568071777
Name:MODER, JACQUELINE H
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:H
Last Name:MODER
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 1:6115 COTTONWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-5992
Mailing Address - Country:US
Mailing Address - Phone:912-286-4400
Mailing Address - Fax:
Practice Address - Street 1:1912 MEMORIAL DR STE E
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-0989
Practice Address - Country:US
Practice Address - Phone:912-283-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11006710363L00000X
GARN240089363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner