Basic Information
| Provider Information | |||||||||
| NPI: | 1124189600 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD, MPH, MPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | UNC DEPARTMENT OF OBSTETRICS AND GYNECOLOGY | ||||||||
| Address2: | 3010 OLD CLINIC BUILDING CB # 7516 | ||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275997516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199666444 | ||||||||
| FaxNumber: | 9199666377 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 10TH AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319013703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065711285 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 02/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | 2015-00684 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 207V00000X | 032570 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | BG3220869 | 01 | GA | DEA REGISTRATION # | OTHER | 695415663A | 05 | GA | MEDICAID |