Provider Demographics
NPI:1154483113
Name:GILLIAM, JACLYN P (CNM)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:P
Last Name:GILLIAM
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 1:1107 E MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5602
Mailing Address - Country:US
Mailing Address - Phone:903-675-8261
Mailing Address - Fax:903-758-3124
Practice Address - Street 1:1761 W LOOP 281
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-2734
Practice Address - Country:US
Practice Address - Phone:903-758-2610
Practice Address - Fax:903-758-7081
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX547421367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124101006Medicaid
TX124101005Medicaid
TX124101006Medicaid
TX8J5339Medicare PIN