Provider Demographics
NPI:1801000385
Name:ANDERSON, JACLYN M (MD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-212-5025
Mailing Address - Fax:859-212-4432
Practice Address - Street 1:7300 TURFWAY RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1375
Practice Address - Country:US
Practice Address - Phone:859-212-5025
Practice Address - Fax:859-212-4432
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41045208000000X
OH35.089541208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY41045OtherKY LICENSE
OH0056986Medicaid
OH35.089541OtherOH LICENSE
IN200994640Medicaid
KY7100016160Medicaid
KY7100016160Medicaid