Provider Demographics
NPI:1558366609
Name:TEBBEN, JACQUELINE KAY (RN-C, PNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KAY
Last Name:TEBBEN
Suffix:
Gender:F
Credentials:RN-C, PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E WENDOVER AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1230
Mailing Address - Country:US
Mailing Address - Phone:336-832-3150
Mailing Address - Fax:
Practice Address - Street 1:301 E WENDOVER AVE
Practice Address - Street 2:STE 400
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1230
Practice Address - Country:US
Practice Address - Phone:336-832-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC300032363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC300032OtherPE#