Provider Demographics
NPI:1427021971
Name:JEGLUM, CAROL L (PAC)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:JEGLUM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:CREDENTIALING
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:800-362-9567
Mailing Address - Fax:608-775-4429
Practice Address - Street 1:112 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:IA
Practice Address - Zip Code:52175-1022
Practice Address - Country:US
Practice Address - Phone:563-422-3811
Practice Address - Fax:563-422-9520
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA1650363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q52329Medicare UPIN