Provider Demographics
NPI:1801880497
Name:ROBERTS, JACQUELYN ELAINE (ARNP)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ELAINE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:ELAINE
Other - Last Name:SHADDIX
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:115 31ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6771
Mailing Address - Country:US
Mailing Address - Phone:229-890-1665
Mailing Address - Fax:229-985-5050
Practice Address - Street 1:115 31ST AVE SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6771
Practice Address - Country:US
Practice Address - Phone:229-890-1665
Practice Address - Fax:229-985-5050
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN128424363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00829617CMedicaid
GA00829617CMedicaid
P37695Medicare UPIN