Basic Information
| Provider Information | |||||||||
| NPI: | 1871556787 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREESE | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | MAE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 OAK ST | ||||||||
| Address2: | P.O. BOX 10 | ||||||||
| City: | SHELDON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 512011242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123245356 | ||||||||
| FaxNumber: | 7123246515 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 OAK ST | ||||||||
| Address2: | |||||||||
| City: | SHELDON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 512011242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123245356 | ||||||||
| FaxNumber: | 7123246515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 04/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 001484 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0254656 | 05 | IA | MEDICAID | 0638593 | 05 | IA | MEDICAID |