Provider Demographics
NPI:1568791259
Name:MOSS, JACLYN IRIS (FNP B-C)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:IRIS
Last Name:MOSS
Suffix:
Gender:F
Credentials:FNP B-C
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:IRIS
Other - Last Name:WHEAT MOSS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP B-C
Mailing Address - Street 1:5482 FIESTA DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2827
Mailing Address - Country:US
Mailing Address - Phone:901-831-1358
Mailing Address - Fax:
Practice Address - Street 1:5482 FIESTA DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2827
Practice Address - Country:US
Practice Address - Phone:901-831-1358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-09
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14186363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04680711Medicaid
TN1524904Medicaid