MEDICARE: JACLYN MICHELLE PRALAT APRN

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	363LP0200X	Pediatric Nurse Practitioner	1002879	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

General Provider Information

NPI Number	:	1295011328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN MICHELLE PRALAT APRN

Provider Business Mailing Address
First Line	:	14100 SAN PEDRO AVE STE 412
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232-2009
Country	:	US
Telephone Number	:	210-281-8669
Fax Number	:	210-314-5044

Provider Business Practice Location Address
First Line	:	10325 LAKE JUNE RD STE 568
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75217-5326
Country	:	US
Telephone Number	:	972-532-9967
Fax Number	:	210-314-5044

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

Provider Enumeration Date	:	11/03/2011
Last Update Date	:	04/29/2021

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