Provider Demographics
NPI:1548763048
Name:BONDHUS, JACLYN (PA-C)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:BONDHUS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3503 CARNELIAN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4224
Mailing Address - Country:US
Mailing Address - Phone:720-560-3152
Mailing Address - Fax:
Practice Address - Street 1:1021 NE 6TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1113
Practice Address - Country:US
Practice Address - Phone:541-507-1881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA187102363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant