Provider Demographics
NPI:1487368049
Name:TAWODA, JACKIE GWENN (FNP)
Entity type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:GWENN
Last Name:TAWODA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MISS
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:268 SADIE LN
Mailing Address - Street 2:
Mailing Address - City:EWING
Mailing Address - State:VA
Mailing Address - Zip Code:24248-8797
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 RIVERVIEW AVE
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977-1452
Practice Address - Country:US
Practice Address - Phone:606-654-4526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3018842363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily