Healthcare Provider Details

I. General information

NPI: 1174660195
Provider Name (Legal Business Name): JACKELINE IACOVELLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E LANCASTER AVE STE 467
WYNNEWOOD PA
19096-3434
US

IV. Provider business mailing address

100 E LANCASTER AVE STE 467
WYNNEWOOD PA
19096-3434
US

V. Phone/Fax

Practice location:
  • Phone: 610-896-0210
  • Fax: 610-896-5101
Mailing address:
  • Phone: 610-896-0210
  • Fax: 610-896-5101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD057529L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: