Provider Demographics
NPI:1972103000
Name:KOSTECKA, JACLYN ANN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JACLYN
Middle Name:ANN
Last Name:KOSTECKA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:ANN
Other - Last Name:BAUTCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10516 GULL POINT RD
Mailing Address - Street 2:
Mailing Address - City:EAST GULL LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3281
Mailing Address - Country:US
Mailing Address - Phone:320-828-0972
Mailing Address - Fax:
Practice Address - Street 1:2014 S 6TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-4529
Practice Address - Country:US
Practice Address - Phone:218-829-7812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant