Provider Demographics
NPI:1659048411
Name:EDMONDS, JACLYN A (CNM)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:A
Last Name:EDMONDS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 W HAMILTON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6970
Mailing Address - Country:US
Mailing Address - Phone:715-552-9784
Mailing Address - Fax:
Practice Address - Street 1:3213 STEIN BLVD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6946
Practice Address - Country:US
Practice Address - Phone:715-836-9242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-27
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI149028175M00000X
WI11355363L00000X
WI367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No175M00000XOther Service ProvidersMidwife, Lay
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner