Basic Information
| Provider Information | |||||||||
| NPI: | 1770835506 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACK | ||||||||
| FirstName: | JACLYNN | ||||||||
| MiddleName: | PAULINE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2620 ELM HILL PIKE | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372143108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154254200 | ||||||||
| FaxNumber: | 6154254268 | ||||||||
| Practice Location | |||||||||
| Address1: | 199 GRACELAND BLVD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432141529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145453001 | ||||||||
| FaxNumber: | 6145453002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2012 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN.CNP.13665 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | COA.13665-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.