Provider Demographics
NPI:1124258967
Name:MINTZ, JACQUELINE (ARNP-FNP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MINTZ
Suffix:
Gender:F
Credentials:ARNP-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 ASHLEY PLACE ROAD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229
Mailing Address - Country:US
Mailing Address - Phone:706-495-6612
Mailing Address - Fax:
Practice Address - Street 1:524 NELSON AVE
Practice Address - Street 2:
Practice Address - City:SHAW AFB
Practice Address - State:SC
Practice Address - Zip Code:29152
Practice Address - Country:US
Practice Address - Phone:706-495-6612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-60208-122363LC1500X
GARN213453363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health