Provider Demographics
NPI:1396747994
Name:DETWEILER, JACQUELYN (DO)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:DETWEILER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:891 E BALTIMORE PIKE
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-1801
Mailing Address - Country:US
Mailing Address - Phone:610-444-0113
Mailing Address - Fax:610-444-0744
Practice Address - Street 1:891 E BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-1801
Practice Address - Country:US
Practice Address - Phone:610-444-0113
Practice Address - Fax:610-444-0744
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07128100208000000X
PAOS009367L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8655707Medicaid