Provider Demographics
NPI:1477674794
Name:JACKLITCH, MICHAEL D (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:JACKLITCH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075-4515
Mailing Address - Country:US
Mailing Address - Phone:701-642-5600
Mailing Address - Fax:701-642-8354
Practice Address - Street 1:320 DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4515
Practice Address - Country:US
Practice Address - Phone:701-642-5600
Practice Address - Fax:701-642-8354
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND351111N00000X
MN1381111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND013374Medicaid
MN90330JAOtherBCBS MN
MN141827100Medicaid
NDN4281Medicare ID - Type Unspecified
MN141827100Medicaid