Provider Demographics
NPI:1295011328
Name:PRALAT, JACLYN MICHELLE (APRN)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MICHELLE
Last Name:PRALAT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:OUSNAMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14100 SAN PEDRO AVE STE 412
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2009
Mailing Address - Country:US
Mailing Address - Phone:210-281-8669
Mailing Address - Fax:210-314-5044
Practice Address - Street 1:10325 LAKE JUNE RD STE 568
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-5326
Practice Address - Country:US
Practice Address - Phone:972-532-9967
Practice Address - Fax:210-314-5044
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1002879363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016270100Medicaid