Provider Demographics
NPI:1831123330
Name:HOWARD, JACLYN L (NP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:L
Last Name:HOWARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2009
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-2009
Mailing Address - Country:US
Mailing Address - Phone:912-764-3800
Mailing Address - Fax:912-871-1901
Practice Address - Street 1:1 W ALTMAN ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5212
Practice Address - Country:US
Practice Address - Phone:912-764-3800
Practice Address - Fax:912-871-1901
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN112664163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS89395Medicare UPIN
GA50BBCZWMedicare ID - Type UnspecifiedBULLOCH HD