Provider Demographics
NPI:1124424536
Name:COLLINS, JACLYN C (FNP)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:C
Last Name:COLLINS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-3139
Mailing Address - Country:US
Mailing Address - Phone:706-745-2111
Mailing Address - Fax:
Practice Address - Street 1:1155 MAIN ST
Practice Address - Street 2:
Practice Address - City:YOUNG HARRIS
Practice Address - State:GA
Practice Address - Zip Code:30582
Practice Address - Country:US
Practice Address - Phone:706-439-6873
Practice Address - Fax:706-439-6874
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN208019363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003161419AMedicaid
NC1124424536Medicaid
GA202I506226Medicare PIN