Provider Demographics
NPI:1790745909
Name:TERWILLIGER, JACQUELINE RENEE (ARNP-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RENEE
Last Name:TERWILLIGER
Suffix:
Gender:F
Credentials:ARNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1833 N PENINSULA AVE
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32169-2017
Mailing Address - Country:US
Mailing Address - Phone:386-423-9355
Mailing Address - Fax:386-423-9355
Practice Address - Street 1:303 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2709
Practice Address - Country:US
Practice Address - Phone:386-254-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1757372363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308261000Medicaid
FLAF456VMedicare PIN