Provider Demographics
NPI:1700214608
Name:HEY, JACLYN C
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:C
Last Name:HEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:C
Other - Last Name:RAPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:711 OLD BALLAS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7068
Mailing Address - Country:US
Mailing Address - Phone:314-569-0510
Mailing Address - Fax:314-569-1085
Practice Address - Street 1:711 OLD BALLAS RD STE 100
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7068
Practice Address - Country:US
Practice Address - Phone:314-569-0510
Practice Address - Fax:314-569-1085
Is Sole Proprietor?:No
Enumeration Date:2013-10-31
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013038962363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO124510082Medicare PIN