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Individual
KATIE JACKLEY
Active
Individual
KATIE JACKLEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
MA051828
PA
363A00000X
Physician Assistant
PA18658
CA
363AM0700X
Medical Physician Assistant
PA18658
CA
363AS0400X
Surgical Physician Assistant
Primary
MA051828
PA
363AS0400X
Surgical Physician Assistant
PA18658
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11680171
CAQH
—
Enumeration date
04/26/2006
Last updated
07/28/2021
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