Provider Demographics
NPI:1285695445
Name:BILELLO, JACLYN RENE (PA-C)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:RENE
Last Name:BILELLO
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 1:211 QUARRY RD STE 305
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-1416
Mailing Address - Country:US
Mailing Address - Phone:650-498-9000
Mailing Address - Fax:215-731-2198
Practice Address - Street 1:211 QUARRY RD STE 305
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1416
Practice Address - Country:US
Practice Address - Phone:650-498-9000
Practice Address - Fax:215-731-2198
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA1713363A00000X
MA1713363AM0700X
CA57936363A00000X
PAMA057542363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1301071Medicaid