Provider Demographics
NPI:1467944199
Name:THAYER, JACQUELYN MARIE
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MARIE
Last Name:THAYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 BAINBRIDGE ST APT 2F
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1373
Mailing Address - Country:US
Mailing Address - Phone:267-844-5791
Mailing Address - Fax:
Practice Address - Street 1:2006 BAINBRIDGE ST APT 2F
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1373
Practice Address - Country:US
Practice Address - Phone:267-844-5791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC203871163WP0808X
NCTHAY-6BQ212363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty