Individual
MRS. JACLYN MARIE DEWALT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
15350 ENGLISH AVE, APPLE VALLEY, MN 55124-6252
(952) 431-8500
Mailing address
8170 33RD AVE S, MS 21110Q, BLOOMINGTON, MN 55425-4516
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
10346
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
475488000
—
MN
Enumeration date
10/01/2007
Last updated
10/14/2024
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