Basic Information
| Provider Information | |||||||||
| NPI: | 1750529384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUNTLY | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1107 E 66TH ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314045701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123508404 | ||||||||
| FaxNumber: | 9123508067 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 E 66TH ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314045701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123508404 | ||||||||
| FaxNumber: | 9123508067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2009 | ||||||||
| LastUpdateDate: | 07/24/2012 | ||||||||
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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 | 208D00000X | 048428 | GA | N | Allopathic & Osteopathic Physicians | General Practice | 2083P0901X | 048428 | GA | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01027627 | 01 | GA | RAILROAD MEDICARE | OTHER | 003116232A | 05 | GA | MEDICAID | GA1255 | 05 | SC | MEDICAID |