Provider Demographics
NPI:1588389480
Name:CHAVIS, JACKIE LOCKLEAR (FNP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:LOCKLEAR
Last Name:CHAVIS
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 1:517 BLACKFOOT TRL
Mailing Address - Street 2:
Mailing Address - City:MAXTON
Mailing Address - State:NC
Mailing Address - Zip Code:28364-6086
Mailing Address - Country:US
Mailing Address - Phone:910-703-2658
Mailing Address - Fax:
Practice Address - Street 1:101 CABARRUS AVE E
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-3699
Practice Address - Country:US
Practice Address - Phone:910-703-2658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-04
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5017020363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCF09221318OtherAMERICAN ACADEMY OF NURSE PRACTITIONER