Provider Demographics
NPI:1588059257
Name:WALL, JACLYN A (MD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:A
Last Name:WALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:JACLYN
Other - Middle Name:ARQUIETTE
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MARRIED NAME
Mailing Address - Street 1:806 SAINT VINCENTS DR STE 500
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-1617
Mailing Address - Country:US
Mailing Address - Phone:205-930-1800
Mailing Address - Fax:
Practice Address - Street 1:806 SAINT VINCENTS DR STE 500
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-1617
Practice Address - Country:US
Practice Address - Phone:205-930-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL38250207VX0201X, 207V00000X
VA0101282855207VX0201X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology