Provider Demographics
NPI:1679347975
Name:FIKE-TAVERAS, JACLYN MICHELLE (AGACNP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MICHELLE
Last Name:FIKE-TAVERAS
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6004 BALCONES CT
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-3319
Mailing Address - Country:US
Mailing Address - Phone:662-202-6485
Mailing Address - Fax:
Practice Address - Street 1:6004 BALCONES CT
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-3319
Practice Address - Country:US
Practice Address - Phone:662-202-6485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1140696363LA2200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health