Provider Demographics
NPI:1831331396
Name:POWELL, JACLYNN L (MD)
Entity type:Individual
Prefix:
First Name:JACLYNN
Middle Name:L
Last Name:POWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACLYNN
Other - Middle Name:LOUISE
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1123 STATE ROUTE 3 NORTH #148
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1715
Mailing Address - Country:US
Mailing Address - Phone:301-614-0595
Mailing Address - Fax:
Practice Address - Street 1:1150 VARNUM ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2104
Practice Address - Country:US
Practice Address - Phone:202-269-7392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350975262085R0202X
DCMD0429062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC063357700Medicaid
DC423479GDBMedicare PIN