1477955284 NPI number — JACQUES JEAN FNP-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477955284 NPI number — JACQUES JEAN FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JEAN
Provider First Name:
JACQUES
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477955284
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5226 FIREBRICK LN SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28025-8807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-260-0037
Provider Business Mailing Address Fax Number:
704-260-0037

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 E 6TH ST
Provider Second Line Business Practice Location Address:
STE 106
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28202-2918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-453-1444
Provider Business Practice Location Address Fax Number:
704-260-0037
Provider Enumeration Date:
09/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  5007327 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: F0814732 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1477955284 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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