Provider Demographics
NPI:1609326776
Name:ANDERSON, JACQUELINE (CRNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:KEELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-812-5888
Mailing Address - Fax:717-741-3709
Practice Address - Street 1:3193 CAPE HORN RD
Practice Address - Street 2:
Practice Address - City:RED LION
Practice Address - State:PA
Practice Address - Zip Code:17356-8810
Practice Address - Country:US
Practice Address - Phone:717-812-5888
Practice Address - Fax:717-741-3709
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP016493363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA548969FLTMedicare PIN