Basic Information
| Provider Information | |||||||||
| NPI: | 1891840120 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2001 TODAYS WOMAN AVE | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271055069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367221818 | ||||||||
| FaxNumber: | 3367221826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 04/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 104882 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363L00000X | 5001629 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 196292 | 01 | NC | MEDCOST | OTHER | NN2912 | 01 | NC | MEDICARE | OTHER | 9185097 | 01 | NC | AETNA | OTHER | 181GT | 01 | NC | BCBS OF NC | OTHER | 7003982 | 05 | NC | MEDICAID |