Provider Demographics
NPI:1710209903
Name:ELMER, JACKLYN MARIE (PA)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:MARIE
Last Name:ELMER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JACKLYN
Other - Middle Name:MARIE
Other - Last Name:ARPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4324 THAMES CT
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-1778
Mailing Address - Country:US
Mailing Address - Phone:254-967-4829
Mailing Address - Fax:
Practice Address - Street 1:4324 THAMES CT
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1778
Practice Address - Country:US
Practice Address - Phone:254-967-4829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TXPA06585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX321033801Medicaid
TX835N10OtherBC/BS TX - EFFECT 02/01/2011
TXP00935316OtherRAILROAD MEDICARE
TXPA06585OtherTX MEDICAL LICENSE
TX816N94OtherBCBS
TXTXB121235OtherMEDICARE PART B - EFFECT 02/01/2011
TXPA06585OtherTX MEDICAL LICENSE
TX292169YKN5Medicare PIN
TX816N94OtherBCBS