Provider Demographics
NPI:1932657764
Name:WRIGHT, JACQUE (BSPP)
Entity Type:Individual
Prefix:
First Name:JACQUE
Middle Name:
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:BSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 E MOORE ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-3364
Mailing Address - Country:US
Mailing Address - Phone:352-870-9289
Mailing Address - Fax:
Practice Address - Street 1:1503 E MOORE ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-3364
Practice Address - Country:US
Practice Address - Phone:352-870-9289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058028919171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor