Provider Demographics
NPI:1912626227
Name:ANDERSON, JACQUELYNN T (PA)
Entity type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:T
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3600 N EDWARDS ST APT 2216
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-5229
Mailing Address - Country:US
Mailing Address - Phone:254-466-9859
Mailing Address - Fax:
Practice Address - Street 1:904 FORD ST
Practice Address - Street 2:
Practice Address - City:LLANO
Practice Address - State:TX
Practice Address - Zip Code:78643-2345
Practice Address - Country:US
Practice Address - Phone:830-953-1700
Practice Address - Fax:830-953-1717
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2025-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA18346363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant