Provider Demographics
NPI:1760807275
Name:GAVIN, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GAVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:GAVIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:808 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GLENOLDEN
Mailing Address - State:PA
Mailing Address - Zip Code:19036-1614
Mailing Address - Country:US
Mailing Address - Phone:610-209-4145
Mailing Address - Fax:
Practice Address - Street 1:808 OAKWOOD DR
Practice Address - Street 2:
Practice Address - City:GLENOLDEN
Practice Address - State:PA
Practice Address - Zip Code:19036-1614
Practice Address - Country:US
Practice Address - Phone:610-209-4145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA100723367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered