Provider Demographics
NPI:1801083126
Name:STODDARD, JACLYN FRANCES (PA-C)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:FRANCES
Last Name:STODDARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6565 WEST MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009
Mailing Address - Country:US
Mailing Address - Phone:269-375-0400
Mailing Address - Fax:269-372-8484
Practice Address - Street 1:6565 WEST MAIN ST.
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009
Practice Address - Country:US
Practice Address - Phone:269-375-0400
Practice Address - Fax:269-372-8484
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005102363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC96159082Medicare PIN
MIM79650045Medicare PIN
MIP08090053Medicare PIN