Healthcare Provider Details

I. General information

NPI: 1588059257
Provider Name (Legal Business Name): JACLYN A WALL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACLYN ARQUIETTE WALL MARRIED NAME

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 SAINT VINCENTS DR STE 500
BIRMINGHAM AL
35205-1617
US

IV. Provider business mailing address

806 SAINT VINCENTS DR STE 500
BIRMINGHAM AL
35205-1617
US

V. Phone/Fax

Practice location:
  • Phone: 205-930-1800
  • Fax:
Mailing address:
  • Phone: 205-930-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number38250
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101282855
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number38250
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number0101282855
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: