Provider Demographics
NPI:1699087411
Name:KNOLL, JACKLYN A (PA-C)
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:A
Last Name:KNOLL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACKLYN
Other - Middle Name:A
Other - Last Name:LEICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 WIND RIDGE DR.
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4173
Mailing Address - Country:US
Mailing Address - Phone:715-847-2611
Mailing Address - Fax:715-847-2612
Practice Address - Street 1:500 WIND RIDGE DR
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4173
Practice Address - Country:US
Practice Address - Phone:715-847-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2622-23363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical