Provider Demographics
NPI:1073283362
Name:THACKER, JACLYNN MARIE (APRN, NP-C)
Entity Type:Individual
Prefix:
First Name:JACLYNN
Middle Name:MARIE
Last Name:THACKER
Suffix:
Gender:F
Credentials:APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W LONGEST ST
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:IN
Mailing Address - Zip Code:47454-8821
Mailing Address - Country:US
Mailing Address - Phone:812-723-3944
Mailing Address - Fax:
Practice Address - Street 1:307 S INDIANA AVE
Practice Address - Street 2:
Practice Address - City:ENGLISH
Practice Address - State:IN
Practice Address - Zip Code:47118-5851
Practice Address - Country:US
Practice Address - Phone:812-338-2924
Practice Address - Fax:812-338-5851
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000761A363LF0000X
IN390200000X
IN71011761A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program