Provider Demographics
NPI:1336559756
Name:ANDERSON, JACQUELINE DAVIS (NURSE TECH II)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:DAVIS
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NURSE TECH II
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:DAVIS
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE TECH II
Mailing Address - Street 1:PO BOX 36053
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27416-6053
Mailing Address - Country:US
Mailing Address - Phone:336-340-3845
Mailing Address - Fax:336-851-2557
Practice Address - Street 1:3300 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-3156
Practice Address - Country:US
Practice Address - Phone:336-327-8854
Practice Address - Fax:336-851-2557
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-07
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC86656374U00000X, 376K00000X, 251J00000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251J00000XAgenciesNursing Care
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty