Provider Demographics
NPI:1538451067
Name:ANDERSON, JACLYN
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11012 CANYON RD E
Mailing Address - Street 2:SUITE #8 PMB #761
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-4200
Mailing Address - Country:US
Mailing Address - Phone:253-279-2721
Mailing Address - Fax:
Practice Address - Street 1:11012 CANYON RD E
Practice Address - Street 2:SUITE #8 PMB #761
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-4200
Practice Address - Country:US
Practice Address - Phone:253-279-2721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAD1 60133612126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant