Healthcare Provider Details

I. General information

NPI: 1063084002
Provider Name (Legal Business Name): JACQUELINE BERNIER HENDERSON MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2021
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S 9TH ST STE 500
PHILADELPHIA PA
19107-6810
US

IV. Provider business mailing address

137 LANDOVER RD
BRYN MAWR PA
19010-3702
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-6175
  • Fax:
Mailing address:
  • Phone: 856-430-8962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP025292
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: