| National Provider Identifier [NPI]: | 1912194291 |
| Last Name Of The Provider | DEWALT |
| First Name Of The Provider | JACLYN |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | PA-C |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 15290 PENNOCK LN |
| Street Address 2 Of The Provider | |
| City Of The Provider | APPLE VALLEY |
| Zip Code Of The Provider | 551247163 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 32 |
| Number Of Services | 197 |
| Number Of Medicare Beneficiaries | 51 |
| Total Submitted Charge Amount | 21618 |
| Total Medicare Allowed Amount | 6766.16 |
| Total Medicare Payment Amount | 4467.2 |
| Total Medicare Standardized Payment Amount | 5649.76 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 8 |
| Number Of Drug Services | 19 |
| Number Of Medicare Beneficiaries With Drug Services | 11 |
| Total Drug Submitted ChargeAmount | 334 |
| Total Drug Medicare AllowedAmount | 179.92 |
| Total Drug Medicare PaymentAmount | 171.55 |
| Total Drug Medicare Standardized Payment Amount | 171.55 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 24 |
| Number Of Medical Services | 178 |
| Number Of Medicare Beneficiaries With Medical Services | 51 |
| Total Medical Submitted Charge Amount | 21284 |
| Total Medical Medicare Allowed Amount | 6586.24 |
| Total Medical Medicare Payment Amount | 4295.65 |
| Total Medical Medicare Standardized Payment Amount | 5478.21 |
| Average Age Of Beneficiaries | 64 |
| Number Of Beneficiaries Age Less65 | 22 |
| Number Of Beneficiaries Age 65 to 74 | 18 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 28 |
| Number Of Male Beneficiaries | 23 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 32 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 19 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 39 |
| Percent Of With Diabetes | 45 |
| Percent Of With Hyperlipidemia | 39 |
| Percent Of With Hypertension | 47 |
| Percent Of With Ischemic Heart Disease | 27 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 33 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9726 |