Provider Demographics
NPI:1811525819
Name:BAKER, JACQUELINE (CRNP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 WISSAHICKON AVE STE 118
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-4248
Mailing Address - Country:US
Mailing Address - Phone:267-597-3600
Mailing Address - Fax:
Practice Address - Street 1:4700 WISSAHICKON AVE STE 110
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-4252
Practice Address - Country:US
Practice Address - Phone:267-597-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP021672363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics