Provider Demographics
NPI:1174535306
Name:DEFFENBAUGH, JACQUELINE (APN, WHNP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:DEFFENBAUGH
Suffix:
Gender:
Credentials:APN, WHNP
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:DEFFENBAUGH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APN, WHNP
Mailing Address - Street 1:2304 STERN DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-4487
Mailing Address - Country:US
Mailing Address - Phone:309-663-0411
Mailing Address - Fax:309-662-2018
Practice Address - Street 1:2304 STERN DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4487
Practice Address - Country:US
Practice Address - Phone:309-663-0411
Practice Address - Fax:309-662-2018
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277000799363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
216064OtherMEDICARE GROUP PTAN
216064OtherMEDICARE GROUP PTAN