Provider Demographics
NPI:1174816672
Name:SANDBERG, JACLYN JOLENE
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:JOLENE
Last Name:SANDBERG
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 1:944 18TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-2608
Mailing Address - Country:US
Mailing Address - Phone:319-961-5664
Mailing Address - Fax:
Practice Address - Street 1:944 18TH AVE SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-2608
Practice Address - Country:US
Practice Address - Phone:319-961-5664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker