Provider Demographics
NPI:1568719540
Name:BOYD, JACQUELINE D (FNP-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:D
Last Name:BOYD
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 PECAN CT
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-6012
Mailing Address - Country:US
Mailing Address - Phone:662-719-9120
Mailing Address - Fax:
Practice Address - Street 1:2622 SOUTHERLAND ST STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4825
Practice Address - Country:US
Practice Address - Phone:601-665-4429
Practice Address - Fax:612-500-4737
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF08170574363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR864187OtherNURSING LICENSE