Basic Information
| Provider Information | |||||||||
| NPI: | 1790745909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TERWILLIGER | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | ARNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1833 N PENINSULA AVE | ||||||||
| Address2: | |||||||||
| City: | NEW SMYRNA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321692017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864239355 | ||||||||
| FaxNumber: | 3864239355 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 N CLYDE MORRIS BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321142709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862544000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 12/02/2016 | ||||||||
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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 | ARNP 1757372 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 308261000 | 05 | FL | MEDICAID |