Provider Demographics
NPI:1366171589
Name:PENSON, JACLYN ANNETTE (PA)
Entity type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:ANNETTE
Last Name:PENSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:ANNETTE
Other - Last Name:TONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:632 COLORADO AVE SW
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51041-1945
Mailing Address - Country:US
Mailing Address - Phone:802-579-4952
Mailing Address - Fax:
Practice Address - Street 1:111 S FRONT ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17101-2010
Practice Address - Country:US
Practice Address - Phone:717-988-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMA065062363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program