MEDICARE: MRS. TERRY PAULSEN JAKOVAC CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN224526L	PA
2	363LX0001X	Obstetrics & Gynecology Nurse Practitioner	TP001134G	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1991407	OTHER	PA	HIGHMARK
2	JA877419	OTHER	PA	HIGHMARK

General Provider Information

NPI Number	:	1043274392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERRY PAULSEN JAKOVAC CRNP

Provider Business Mailing Address
First Line	:	451 HYDE PARK RD
Second Line	:	HYDE PARK PLAZA
City	:	LEECHBURG
State	:	PA
Zip	:	15656-9417
Country	:	US
Telephone Number	:	724-282-3756
Fax Number	:	724-282-8995

Provider Business Practice Location Address
First Line	:	451 HYDE PARK RD
Second Line	:	HYDE PARK PLAZA
City	:	LEECHBURG
State	:	PA
Zip	:	15656-9417
Country	:	US
Telephone Number	:	724-282-3756
Fax Number	:	724-282-8995

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2006
Last Update Date	:	12/20/2011

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