Provider Demographics
NPI:1174660195
Name:IACOVELLA, JACKELINE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKELINE
Middle Name:
Last Name:IACOVELLA
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 1:2100 KEYSTONE AVE
Mailing Address - Street 2:SUITE 406
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-1129
Mailing Address - Country:US
Mailing Address - Phone:610-622-8900
Mailing Address - Fax:610-622-8904
Practice Address - Street 1:2100 KEYSTONE AVE
Practice Address - Street 2:SUITE 406
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-1129
Practice Address - Country:US
Practice Address - Phone:610-622-8900
Practice Address - Fax:610-622-8904
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD057529L207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001792248Medicaid
PAG62243Medicare UPIN
PA001792248Medicaid