Provider Demographics
NPI:1487743217
Name:WEVODAU, JACQUELINE ANN (MS, PA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:WEVODAU
Suffix:
Gender:F
Credentials:MS, PA
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:WEVODAU
Other - Last Name:ROHRBAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, PA
Mailing Address - Street 1:5885 AVIS LANE
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17112-1606
Mailing Address - Country:US
Mailing Address - Phone:717-602-8204
Mailing Address - Fax:
Practice Address - Street 1:2005 TECHNOLOGY PKWY STE 400
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050
Practice Address - Country:US
Practice Address - Phone:717-791-2520
Practice Address - Fax:717-703-0061
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103148481Medicaid