Provider Demographics
NPI:1578568358
Name:JACQUET, NELSON (PA)
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:
Last Name:JACQUET
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WHITCHER ST NE
Mailing Address - Street 2:STE 350
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1155
Mailing Address - Country:US
Mailing Address - Phone:770-424-6893
Mailing Address - Fax:770-424-9095
Practice Address - Street 1:55 WHITCHER ST NE
Practice Address - Street 2:STE 350
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1155
Practice Address - Country:US
Practice Address - Phone:770-424-6893
Practice Address - Fax:770-424-9095
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004350363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA180068957DMedicaid
GA180068957FMedicaid
GA180068957BMedicaid
GA180068957CMedicaid
GA180068957EMedicaid
GAQ22072Medicare UPIN
GA180068957FMedicaid