Provider Demographics
NPI:1992332167
Name:THIEMAN, JACQUELINE (PA-C)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:THIEMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 OLD LANCASTER RD STE 440
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3236
Mailing Address - Country:US
Mailing Address - Phone:610-527-4896
Mailing Address - Fax:
Practice Address - Street 1:825 OLD LANCASTER RD STE 440
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3236
Practice Address - Country:US
Practice Address - Phone:610-527-4896
Practice Address - Fax:610-525-4089
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061420363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant