Provider Demographics
NPI:1114098431
Name:PEVNY, JACQUELINE B (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:B
Last Name:PEVNY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 DEVON CT
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33445-7111
Mailing Address - Country:US
Mailing Address - Phone:561-272-4888
Mailing Address - Fax:561-265-5035
Practice Address - Street 1:2640 DEVON CT
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-7111
Practice Address - Country:US
Practice Address - Phone:561-272-4888
Practice Address - Fax:561-265-5035
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME813822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU0683Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
FLH06135Medicare UPIN