Provider Demographics
NPI:1770835506
Name:BACK, JACLYNN PAULINE (CNP)
Entity Type:Individual
Prefix:MISS
First Name:JACLYNN
Middle Name:PAULINE
Last Name:BACK
Suffix:
Gender:F
Credentials:CNP
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Mailing Address - Street 1:2620 ELM HILL PIKE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37214-3108
Mailing Address - Country:US
Mailing Address - Phone:615-425-4200
Mailing Address - Fax:615-425-4268
Practice Address - Street 1:199 GRACELAND BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-1529
Practice Address - Country:US
Practice Address - Phone:614-545-3001
Practice Address - Fax:614-545-3002
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2020-02-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.13665363L00000X
OHCOA.13665-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner