Provider Demographics
NPI:1982310710
Name:WOODSIDE, JACKIE MARLENE (APRN)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:MARLENE
Last Name:WOODSIDE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02813-3322
Mailing Address - Country:US
Mailing Address - Phone:401-364-1268
Mailing Address - Fax:
Practice Address - Street 1:51 OLD MILL RD
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:RI
Practice Address - Zip Code:02813-3322
Practice Address - Country:US
Practice Address - Phone:401-364-1268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN04100363L00000X
RIRN58926390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program