Provider Demographics
NPI:1952751299
Name:CONDO, JACLYN MILLER (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:MILLER
Last Name:CONDO
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 1:3099 HELMSDALE PL
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2213
Mailing Address - Country:US
Mailing Address - Phone:859-258-6401
Mailing Address - Fax:859-258-6438
Practice Address - Street 1:UK UROLOGY CLINIC
Practice Address - Street 2:740 S LIMESTONE STE B200
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536
Practice Address - Country:US
Practice Address - Phone:859-257-3533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-17
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY363A00000X
KYPA2320363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical