Basic Information
| Provider Information | |||||||||
| NPI: | 1164675179 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAVERNA | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | FNP-BC, MSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 S B B KING BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014361381 | ||||||||
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| Practice Location | |||||||||
| Address1: | 520 E KENDALL DR UNIT C | ||||||||
| Address2: | |||||||||
| City: | YORKVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605601956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303852360 | ||||||||
| FaxNumber: | 6303852934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2008 | ||||||||
| LastUpdateDate: | 04/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 277.001828 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 209.007311 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.