Provider Demographics
NPI:1124010004
Name:BAUER, JACQUELYN P (CRNP)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:P
Last Name:BAUER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13210 GROWDENVALE DR NE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-6844
Mailing Address - Country:US
Mailing Address - Phone:301-724-7616
Mailing Address - Fax:301-724-4811
Practice Address - Street 1:500 GREENE ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2755
Practice Address - Country:US
Practice Address - Phone:301-724-7616
Practice Address - Fax:301-724-4811
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR110105363LN0000X, 363LP0200X
PASP018623363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103470021Medicaid
MD126751500Medicaid
WV0167161000Medicaid