Provider Demographics
NPI:1609219039
Name:SELPH, JACQUELINE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:SELPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:15 MARKET CENTER DR STE A
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:NC
Mailing Address - Zip Code:28731-8529
Mailing Address - Country:US
Mailing Address - Phone:828-697-1170
Mailing Address - Fax:828-698-4939
Practice Address - Street 1:15 MARKET CENTER DR STE A
Practice Address - Street 2:
Practice Address - City:FLAT ROCK
Practice Address - State:NC
Practice Address - Zip Code:28731-8529
Practice Address - Country:US
Practice Address - Phone:286-978-1170
Practice Address - Fax:828-698-4939
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD84894207N00000X
NC2019-00922207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC006815480OtherUHC
NCP02346770OtherRAILROAD MEDICARE
NC205L8OtherBCBS NC
NCNN9352F459OtherMEDICARE