MEDICARE: DR. JACLYN M ELIASSEN DDS

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	1223G0001X	General Practice Dentistry	DE60575246	WA

General Provider Information

NPI Number	:	1720462666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACLYN M ELIASSEN DDS

Provider Business Mailing Address
First Line	:	5011 W LOWELL AVE
Second Line	:	SUITE 130
City	:	SPOKANE
State	:	WA
Zip	:	99208-8587
Country	:	US
Telephone Number	:	509-464-3100
Fax Number	:

Provider Business Practice Location Address
First Line	:	5011 W LOWELL AVE
Second Line	:	SUITE 130
City	:	SPOKANE
State	:	WA
Zip	:	99208-8587
Country	:	US
Telephone Number	:	509-464-3100
Fax Number	:

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

Provider Enumeration Date	:	07/09/2015
Last Update Date	:	12/09/2025

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