Provider Demographics
NPI:1326264441
Name:JACKLIN, JENNIFER JOY (CPNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JOY
Last Name:JACKLIN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 HOLLYBEND DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-6537
Mailing Address - Country:US
Mailing Address - Phone:314-276-1428
Mailing Address - Fax:
Practice Address - Street 1:10777 SUNSET OFFICE DR STE 110
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1019
Practice Address - Country:US
Practice Address - Phone:314-781-7415
Practice Address - Fax:314-644-4592
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO152024363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics