Provider Demographics
NPI:1578367363
Name:NICASIO, JACLYN (NP)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:NICASIO
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17220
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46217-0220
Mailing Address - Country:US
Mailing Address - Phone:765-298-4220
Mailing Address - Fax:
Practice Address - Street 1:1629 MEDICAL ARTS BLVD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3454
Practice Address - Country:US
Practice Address - Phone:765-298-4220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71016449A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner