Provider Demographics
NPI:1952721672
Name:JACOBS, KELLEY WALLACE (DNP/FNP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:WALLACE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:DNP/FNP
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:LYNN
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:705 N 8TH AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:SC
Mailing Address - Zip Code:29536-2549
Mailing Address - Country:US
Mailing Address - Phone:843-774-2478
Mailing Address - Fax:843-774-1826
Practice Address - Street 1:705 N 8TH AVE STE 1A
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-2549
Practice Address - Country:US
Practice Address - Phone:843-774-2478
Practice Address - Fax:843-774-1826
Is Sole Proprietor?:No
Enumeration Date:2014-04-21
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18972363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care