Provider Demographics
NPI:1255807087
Name:THORNTON, JACLYN BLAIR (NP)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:BLAIR
Last Name:THORNTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:BLAIR
Other - Last Name:LUCCHESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:9 CLAIRE DR
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29928-3937
Mailing Address - Country:US
Mailing Address - Phone:901-485-3766
Mailing Address - Fax:
Practice Address - Street 1:PAIN SPECIALIST IT SOUTHERN OREGON
Practice Address - Street 2:825 BENNETT AVE
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-779-5228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10003878207QA0505X
SC22326363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care