Healthcare Provider Details

I. General information

NPI: 1467944199
Provider Name (Legal Business Name): JACQUELYN MARIE THAYER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 05/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2006 BAINBRIDGE ST APT 2F
PHILADELPHIA PA
19146-1373
US

IV. Provider business mailing address

2006 BAINBRIDGE ST APT 2F
PHILADELPHIA PA
19146-1373
US

V. Phone/Fax

Practice location:
  • Phone: 267-844-5791
  • Fax:
Mailing address:
  • Phone: 267-844-5791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number203871
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberTHAY-6BQ212
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: