Basic Information
| Provider Information | |||||||||
| NPI: | 1437296860 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMECK | ||||||||
| FirstName: | JACQUITA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | C.R.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 910 ADAMS ST SE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358013730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565337420 | ||||||||
| FaxNumber: | 2565364109 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 ADAMS ST SE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358013730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565337420 | ||||||||
| FaxNumber: | 2565364109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 10/30/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 1-035752 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 51076937 | 01 | AL | BCBS | OTHER | D084 | 01 | AL | MEDICARE | OTHER | G423 | 01 | AL | MEDICARE | OTHER | E709 | 01 | AL | MEDICARE | OTHER |