Provider Demographics
NPI:1710343686
Name:BRABEC, JACLYN SARA (PA-C)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:SARA
Last Name:BRABEC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2561 S 1560 W UNIT B
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84087-2361
Mailing Address - Country:US
Mailing Address - Phone:801-505-0821
Mailing Address - Fax:801-505-0803
Practice Address - Street 1:2376 N 400 E STE 202
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-3413
Practice Address - Country:US
Practice Address - Phone:801-906-1403
Practice Address - Fax:801-964-6478
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT12330762-1206363A00000X
IDPA-1337363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12330762-1206OtherLICENSE