Provider Demographics
NPI:1245583665
Name:DEPANFILIS, JACKI RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACKI
Middle Name:RENEE
Last Name:DEPANFILIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACKI
Other - Middle Name:RENEE
Other - Last Name:DAVISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:104 METOXET ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIDGWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15853-1932
Mailing Address - Country:US
Mailing Address - Phone:814-772-8122
Mailing Address - Fax:814-772-7278
Practice Address - Street 1:104 METOXET ST
Practice Address - Street 2:SUITE A
Practice Address - City:RIDGWAY
Practice Address - State:PA
Practice Address - Zip Code:15853-1932
Practice Address - Country:US
Practice Address - Phone:814-772-8122
Practice Address - Fax:814-772-7278
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055834363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical