Provider Demographics
NPI:1124598792
Name:JACKMAN, KAITLYN NICOLE
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:NICOLE
Last Name:JACKMAN
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 1:6320 ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66226
Mailing Address - Country:US
Mailing Address - Phone:913-240-7194
Mailing Address - Fax:
Practice Address - Street 1:6320 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66226
Practice Address - Country:US
Practice Address - Phone:913-240-7194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer