Provider Demographics
NPI:1659610764
Name:MAHLSTEDE, JACLYN (ARNP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:MAHLSTEDE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MS 315010
Mailing Address - Street 2:PO BOX 3947
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-3947
Mailing Address - Country:US
Mailing Address - Phone:425-467-3655
Mailing Address - Fax:425-835-6388
Practice Address - Street 1:1135-116TH AVENUE NE
Practice Address - Street 2:SUITE 200
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004
Practice Address - Country:US
Practice Address - Phone:520-324-2160
Practice Address - Fax:520-324-1460
Is Sole Proprietor?:No
Enumeration Date:2013-02-08
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA60820546363LF0000X
WAAP60820546363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2145072Medicaid
AZ791187Medicaid