Provider Demographics
NPI:1760082119
Name:BUSHELL, JACQUELINE ROSEANN (RN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ROSEANN
Last Name:BUSHELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 RIVERLOCH WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-4488
Mailing Address - Country:US
Mailing Address - Phone:678-863-6859
Mailing Address - Fax:
Practice Address - Street 1:925 SANDERS RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7945
Practice Address - Country:US
Practice Address - Phone:678-261-7671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN177666163WC0400X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC0400XNursing Service ProvidersRegistered NurseCase Management