Provider Demographics
NPI:1033760624
Name:DUBOIS, JACLYN (CNM)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:DUBOIS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 S 600 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1218
Mailing Address - Country:US
Mailing Address - Phone:978-495-2607
Mailing Address - Fax:
Practice Address - Street 1:14502 W MEEKER BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5282
Practice Address - Country:US
Practice Address - Phone:623-524-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTCNM05705367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife