Provider Demographics
NPI:1962642744
Name:SNEED, JACLYN N (PA)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:N
Last Name:SNEED
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 MEMORIAL DR STE 120
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5359
Mailing Address - Country:US
Mailing Address - Phone:618-222-1020
Mailing Address - Fax:
Practice Address - Street 1:4600 MEMORIAL DR STE 120
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5359
Practice Address - Country:US
Practice Address - Phone:618-222-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-06
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01727363A00000X
IL085.004206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085.004206OtherILLINOIS MEDICAL LICENSE-PHYSICIAN ASSISTANT
NC0010-01727OtherSTATE LICENSE