Provider Demographics
NPI:1508416173
Name:DEGEN, JACQUELINE (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:DEGEN
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SPENCERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45887-1329
Mailing Address - Country:US
Mailing Address - Phone:419-230-9861
Mailing Address - Fax:
Practice Address - Street 1:580 LINCOLN PARK BOULEVARD
Practice Address - Street 2:SUITE 320
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-3493
Practice Address - Country:US
Practice Address - Phone:937-299-6980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.023831363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner