Provider Demographics
NPI:1801403878
Name:WALSH, JACLYN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:WALSH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 GRAND CANYON CT
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-1784
Mailing Address - Country:US
Mailing Address - Phone:862-216-8434
Mailing Address - Fax:
Practice Address - Street 1:1011 E SONGSMITH DR
Practice Address - Street 2:
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-1194
Practice Address - Country:US
Practice Address - Phone:302-918-7509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0011436363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant