Provider Demographics
NPI:1093213118
Name:KAMARA, JACKLYNE W
Entity Type:Individual
Prefix:
First Name:JACKLYNE
Middle Name:W
Last Name:KAMARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 78TH AVE N STE 101
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445-2719
Mailing Address - Country:US
Mailing Address - Phone:763-432-6875
Mailing Address - Fax:218-724-4041
Practice Address - Street 1:6900 78TH AVE N STE 101
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55445-2719
Practice Address - Country:US
Practice Address - Phone:571-317-1792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-23
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty