Provider Demographics
NPI:1316388077
Name:THOMPSON, JACLYN (PA-C)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:MOSCARIELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:67 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1328
Mailing Address - Country:US
Mailing Address - Phone:203-732-1330
Mailing Address - Fax:203-732-1332
Practice Address - Street 1:224 LEAVENWORTH RD
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-1881
Practice Address - Country:US
Practice Address - Phone:203-926-1206
Practice Address - Fax:203-926-0413
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002923363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant