Provider Demographics
NPI:1801403654
Name:RICHART, JACQUELINE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:RICHART
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5333 BRENDLYNN DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7556
Mailing Address - Country:US
Mailing Address - Phone:816-352-0121
Mailing Address - Fax:
Practice Address - Street 1:6300 HOSPITAL PKWY STE 260
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1829
Practice Address - Country:US
Practice Address - Phone:770-454-4685
Practice Address - Fax:770-454-4690
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN280432363L00000X
TX2016013133363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner