Provider Demographics
NPI:1568711034
Name:PELLENBARG, JACQUELINE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:PELLENBARG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:FREEBERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:200 HYGEIA DR STE 2300
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4701 OGLETOWN STANTON RD STE 2100
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-7000
Practice Address - Country:US
Practice Address - Phone:302-623-4530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
DEC5-0001057363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical