Provider Demographics
NPI:1003813767
Name:KMENT, JACKLYNN A (PA-C)
Entity Type:Individual
Prefix:
First Name:JACKLYNN
Middle Name:A
Last Name:KMENT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACKLYNN
Other - Middle Name:A
Other - Last Name:FITZKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1620 S 70TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-1563
Mailing Address - Country:US
Mailing Address - Phone:402-318-3550
Mailing Address - Fax:402-318-3546
Practice Address - Street 1:1620 S 70TH ST STE 103
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-1563
Practice Address - Country:US
Practice Address - Phone:402-318-3550
Practice Address - Fax:402-318-3546
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE598363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE970013133OtherRAILROAD MEDICARE
NE37758OtherBLUE SHIELD
NE47065843713Medicaid
NE37758OtherBLUE SHIELD
NE273153Medicare ID - Type Unspecified