Provider Demographics
NPI:1962119560
Name:HINES, JACQUELINE KELLI
Entity type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:KELLI
Last Name:HINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 AVENT RIDGE RD APT 201
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-4796
Mailing Address - Country:US
Mailing Address - Phone:919-332-9751
Mailing Address - Fax:
Practice Address - Street 1:1821 AVENT RIDGE RD APT 201
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-4796
Practice Address - Country:US
Practice Address - Phone:919-332-9751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician