Provider Demographics
NPI:1427758747
Name:ROBLES, JACLYN ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:ROSE
Last Name:ROBLES
Suffix:
Gender:
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 1:1016 SEGUNDO DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-1734
Mailing Address - Country:US
Mailing Address - Phone:218-370-9361
Mailing Address - Fax:
Practice Address - Street 1:PO BOX A
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359-0807
Practice Address - Country:US
Practice Address - Phone:320-532-3154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN14453OtherPA-C LICENSE