Provider Demographics
NPI:1679136311
Name:NEELY, JACKEE L (CERTIFIED NURSE ASST)
Entity Type:Individual
Prefix:
First Name:JACKEE
Middle Name:L
Last Name:NEELY
Suffix:
Gender:F
Credentials:CERTIFIED NURSE ASST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N MCDOWELL ST UNIT 30843
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28230-0077
Mailing Address - Country:US
Mailing Address - Phone:704-630-2268
Mailing Address - Fax:
Practice Address - Street 1:834 TYVOLA RD STE 108
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217
Practice Address - Country:US
Practice Address - Phone:704-630-2268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC523821376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide