Provider Demographics
NPI:1265716344
Name:BACON, JACLYN (FNP-C)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10238 E HAMPTON AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3316
Mailing Address - Country:US
Mailing Address - Phone:623-512-4390
Mailing Address - Fax:623-512-4391
Practice Address - Street 1:10238 E HAMPTON AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-3316
Practice Address - Country:US
Practice Address - Phone:623-512-4390
Practice Address - Fax:623-512-4391
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4198363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily