Basic Information
| Provider Information | |||||||||
| NPI: | 1457355299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEBB | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14558 DANVILLE PIKE | ||||||||
| Address2: | |||||||||
| City: | LAUREL FORK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243523982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763982292 | ||||||||
| FaxNumber: | 2733983331 | ||||||||
| Practice Location | |||||||||
| Address1: | 14558 DANVILLE PIKE | ||||||||
| Address2: | |||||||||
| City: | LAUREL FORK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243523982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763982292 | ||||||||
| FaxNumber: | 2733983331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 0024134336 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 007608942 | 05 | VA | MEDICAID |