Individual
JACQUELINE DEFFENBAUGH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
APN, WHNP
Contact information
Practice address
2304 STERN DR, BLOOMINGTON, IL 61704-4487
(309) 663-0411
(309) 662-2018
Mailing address
2304 STERN DR, BLOOMINGTON, IL 61704-4487
(309) 663-0411
(309) 662-2018
Taxonomy
Speciality
Code
Description
License number
State
363LW0102X
Women's Health Nurse Practitioner
Primary
277000799
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
216064
MEDICARE GROUP PTAN
—
Enumeration date
08/13/2006
Last updated
04/22/2025
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