Provider Demographics
NPI:1740661693
Name:TYSON, JACLYN RAE (CRNP)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:RAE
Last Name:TYSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:RAE
Other - Last Name:BIVALETZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNP
Mailing Address - Street 1:95 HIGHLAND AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017-9483
Mailing Address - Country:US
Mailing Address - Phone:484-503-8281
Mailing Address - Fax:
Practice Address - Street 1:95 HIGHLAND AVE STE 130
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-9483
Practice Address - Country:US
Practice Address - Phone:484-503-8281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014350363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily