Healthcare Provider Details

I. General information

NPI: 1134904287
Provider Name (Legal Business Name): JACY BAYLESS ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PERSHING AVE
SHENANDOAH IA
51601-2355
US

IV. Provider business mailing address

600 WEST ST
SHENANDOAH IA
51601-1935
US

V. Phone/Fax

Practice location:
  • Phone: 712-246-7400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA175904
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: