Provider Demographics
NPI:1184759649
Name:JULTY, JACQUELINE (PA-C)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:JULTY
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 1:2500 GRANT RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-4302
Mailing Address - Country:US
Mailing Address - Phone:650-940-7000
Mailing Address - Fax:
Practice Address - Street 1:3801 MIRANDA AVE
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1207
Practice Address - Country:US
Practice Address - Phone:650-498-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 11877363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS28207Medicare UPIN
CAEP338ZMedicare PIN