Provider Demographics
NPI:1265040448
Name:ELAM, JACLYN HINKLE (APRN)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:HINKLE
Last Name:ELAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2603
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76113-2603
Mailing Address - Country:US
Mailing Address - Phone:817-335-3022
Mailing Address - Fax:
Practice Address - Street 1:3840 HULEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7277
Practice Address - Country:US
Practice Address - Phone:817-335-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1002434363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty