Basic Information
| Provider Information | |||||||||
| NPI: | 1477197424 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAUGHERTY | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | BLAIRE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP-PMH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 604 SOLAREX CT UNIT 201 | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217038655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016638263 | ||||||||
| FaxNumber: | 3016825326 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 SOLAREX CT UNIT 201 | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217038655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016638263 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2019 | ||||||||
| LastUpdateDate: | 03/04/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | R204851 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.