Provider Demographics
NPI:1831308527
Name:BLAND, JACLYN NICOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:NICOLE
Last Name:BLAND
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 1:200 ROUTE 98 W ST
Mailing Address - Street 2:310
Mailing Address - City:NUTTER FORT
Mailing Address - State:WV
Mailing Address - Zip Code:26301-4385
Mailing Address - Country:US
Mailing Address - Phone:302-624-0980
Mailing Address - Fax:304-624-0095
Practice Address - Street 1:200 ROUTE 98 W ST
Practice Address - Street 2:310
Practice Address - City:NUTTER FORT
Practice Address - State:WV
Practice Address - Zip Code:26301-4385
Practice Address - Country:US
Practice Address - Phone:302-624-0980
Practice Address - Fax:304-624-0095
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01038363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPA22701Medicare ID - Type Unspecified