Provider Demographics
NPI:1710141742
Name:MCINTOSH-GRANT, JACQUELINE V (RN BA)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:V
Last Name:MCINTOSH-GRANT
Suffix:
Gender:F
Credentials:RN BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3990 EMBASSY WAY
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-7828
Mailing Address - Country:US
Mailing Address - Phone:678-485-4112
Mailing Address - Fax:
Practice Address - Street 1:1105 WEST PEACHTREE ST NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-3608
Practice Address - Country:US
Practice Address - Phone:404-853-2800
Practice Address - Fax:404-759-2753
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN071576163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse