Provider Demographics
NPI:1578614269
Name:POLGE, JACKIE (FNP)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:POLGE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 SW BALMORAL TRCE
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-4203
Mailing Address - Country:US
Mailing Address - Phone:772-349-5737
Mailing Address - Fax:
Practice Address - Street 1:936 SW BALMORAL TRCE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-4203
Practice Address - Country:US
Practice Address - Phone:772-349-5737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9367097363LF0000X
NY331180363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily