Provider Demographics
NPI:1366766735
Name:GILL, JACLYN NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:NICOLE
Last Name:GILL
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 1:6400 CLAYTON RD
Mailing Address - Street 2:STE 110
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1850
Mailing Address - Country:US
Mailing Address - Phone:314-645-4434
Mailing Address - Fax:314-645-3801
Practice Address - Street 1:6400 CLAYTON RD
Practice Address - Street 2:STE 110
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1850
Practice Address - Country:US
Practice Address - Phone:314-645-4434
Practice Address - Fax:314-645-3801
Is Sole Proprietor?:No
Enumeration Date:2010-03-15
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
MO2010008198207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO147400032Medicare PIN
MO147480032Medicare PIN