Provider Demographics
NPI:1346504248
Name:ACKERMAN, JACKLYN
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:ACKERMAN
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 1:2430 PARTRIDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-4944
Mailing Address - Country:US
Mailing Address - Phone:208-964-3357
Mailing Address - Fax:
Practice Address - Street 1:2430 PARTRIDGE LOOP
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-4944
Practice Address - Country:US
Practice Address - Phone:208-964-3357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion