Provider Demographics
NPI:1083044788
Name:JACKMAN, KAITLIN (DH)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:DH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2473
Mailing Address - Country:US
Mailing Address - Phone:509-494-6700
Mailing Address - Fax:509-573-6275
Practice Address - Street 1:1206 N DOLARWAY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-8392
Practice Address - Country:US
Practice Address - Phone:509-933-2400
Practice Address - Fax:509-933-4804
Is Sole Proprietor?:No
Enumeration Date:2013-11-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH60303163124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist