Provider Demographics
NPI:1972868651
Name:ROGERS, JACLYN JEAN (PA)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:JEAN
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 MESA VALLEY WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-6856
Mailing Address - Country:US
Mailing Address - Phone:770-944-1100
Mailing Address - Fax:770-944-6469
Practice Address - Street 1:2041 MESA VALLEY WAY STE 100
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6856
Practice Address - Country:US
Practice Address - Phone:770-944-1100
Practice Address - Fax:770-944-6469
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5361111N00000X
KYTC837363A00000X
GA10202363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No111N00000XChiropractic ProvidersChiropractor