Provider Demographics
NPI:1447920848
Name:HAZELWONDER, JACLYN (MSN, APRN, FNP-BC)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:HAZELWONDER
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 HURSTBOROUGH MANOR DR
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-1584
Mailing Address - Country:US
Mailing Address - Phone:314-625-8821
Mailing Address - Fax:
Practice Address - Street 1:222 S WOODS MILL RD # 550
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3625
Practice Address - Country:US
Practice Address - Phone:314-434-3049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021034991363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily