Provider Demographics
NPI:1164675179
Name:TAVERNA, JACLYN K (FNP-BC, MSN)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:K
Last Name:TAVERNA
Suffix:
Gender:F
Credentials:FNP-BC, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 S B B KING BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2626
Mailing Address - Country:US
Mailing Address - Phone:901-436-1381
Mailing Address - Fax:
Practice Address - Street 1:520 E KENDALL DR UNIT C
Practice Address - Street 2:
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-1956
Practice Address - Country:US
Practice Address - Phone:630-385-2360
Practice Address - Fax:630-385-2934
Is Sole Proprietor?:No
Enumeration Date:2008-11-04
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277.001828363L00000X
IL209.007311363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily