Provider Demographics
NPI:1417113325
Name:SUTTER, JACQUELINE BURLETT (DO)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:BURLETT
Last Name:SUTTER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LANCASTER AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3451
Mailing Address - Country:US
Mailing Address - Phone:610-642-3796
Mailing Address - Fax:610-642-3796
Practice Address - Street 1:100 E LANCASTER AVE STE 230
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096
Practice Address - Country:US
Practice Address - Phone:610-642-3796
Practice Address - Fax:610-642-2943
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT011365207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1025915970002Medicaid