Provider Demographics
NPI:1215531280
Name:HEADLEY, JACQUELINE MICHELE (BSN RN)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MICHELE
Last Name:HEADLEY
Suffix:
Gender:F
Credentials:BSN RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2887 OPHELIA WAY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-6784
Mailing Address - Country:US
Mailing Address - Phone:734-621-3158
Mailing Address - Fax:
Practice Address - Street 1:700 21ST AVE N
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-7400
Practice Address - Country:US
Practice Address - Phone:843-448-8407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC244146163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health