Provider Demographics
NPI:1710613757
Name:SIDES, JACKIE SMITH
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:SMITH
Last Name:SIDES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 WILKES DR APT C7
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-2731
Mailing Address - Country:US
Mailing Address - Phone:704-465-5348
Mailing Address - Fax:
Practice Address - Street 1:1408 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5160
Practice Address - Country:US
Practice Address - Phone:704-625-2080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-30
Last Update Date:2022-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC71366164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse