Provider Demographics
NPI:1558757096
Name:VANDERBURGH, JACQUELINE MAY (DO)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MAY
Last Name:VANDERBURGH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WYOMING ST
Mailing Address - Street 2:STE 1601
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2722
Mailing Address - Country:US
Mailing Address - Phone:937-208-4250
Mailing Address - Fax:
Practice Address - Street 1:1601 23RD AVE S
Practice Address - Street 2:SUITE 3105 VPH
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-3133
Practice Address - Country:US
Practice Address - Phone:615-327-7119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-11
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.0146252084P0800X
TN34992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry