Provider Demographics
NPI:1922436682
Name:HERBERT, JACQUELYN M
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:M
Last Name:HERBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:M
Other - Last Name:SPENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3315 N SEMINARY ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-1251
Mailing Address - Country:US
Mailing Address - Phone:309-344-1000
Mailing Address - Fax:309-344-2405
Practice Address - Street 1:3315 N SEMINARY ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1251
Practice Address - Country:US
Practice Address - Phone:309-344-1000
Practice Address - Fax:309-344-2405
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004892363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant