MEDICARE: JACLYN P GILLIAM CNM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367A00000X	Advanced Practice Midwife	AP109416	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154483113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN P GILLIAM CNM

Provider Business Mailing Address
First Line	:	1107 E MARSHALL AVE
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75601-5602
Country	:	US
Telephone Number	:	903-675-8261
Fax Number	:	903-758-3124

Provider Business Practice Location Address
First Line	:	1761 W LOOP 281
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75604-2734
Country	:	US
Telephone Number	:	903-758-2610
Fax Number	:	903-758-7081

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	08/26/2025

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