Provider Demographics
NPI:1851068407
Name:VALENCIA, JALYSSA ERICKA
Entity Type:Individual
Prefix:
First Name:JALYSSA
Middle Name:ERICKA
Last Name:VALENCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 S HIGHWAY 69
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-9310
Mailing Address - Country:US
Mailing Address - Phone:918-485-6069
Mailing Address - Fax:
Practice Address - Street 1:2109 S HIGHWAY 69
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-9310
Practice Address - Country:US
Practice Address - Phone:918-485-6069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical