Provider Demographics
NPI:1750419966
Name:ADKINS, JACLYN LEA (PA)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:LEA
Last Name:ADKINS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 30 BOX 56
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:WV
Mailing Address - Zip Code:24925
Mailing Address - Country:US
Mailing Address - Phone:304-645-1463
Mailing Address - Fax:
Practice Address - Street 1:645 KANAWHA AVE
Practice Address - Street 2:
Practice Address - City:RAINELLE
Practice Address - State:WV
Practice Address - Zip Code:25962-1013
Practice Address - Country:US
Practice Address - Phone:304-438-6188
Practice Address - Fax:304-438-6819
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00866363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVADPA33511Medicare PIN