Provider Demographics
NPI:1477793214
Name:AHDUNKO, JACKY
Entity Type:Individual
Prefix:
First Name:JACKY
Middle Name:
Last Name:AHDUNKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKY
Other - Middle Name:
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 209
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89504-0209
Mailing Address - Country:US
Mailing Address - Phone:775-324-2622
Mailing Address - Fax:775-324-0446
Practice Address - Street 1:335 RECORD ST.
Practice Address - Street 2:SUITE 155
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89512-3327
Practice Address - Country:US
Practice Address - Phone:775-324-2622
Practice Address - Fax:775-324-0446
Is Sole Proprietor?:No
Enumeration Date:2009-03-05
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health