Basic Information
| Provider Information | |||||||||
| NPI: | 1558366609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEBBEN | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | RN-C, PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 E WENDOVER AVE | ||||||||
| Address2: | STE 400 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368323150 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 301 E WENDOVER AVE | ||||||||
| Address2: | STE 400 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368323150 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 04/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 300032 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | 300032 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.