Provider Demographics
NPI:1487182663
Name:BACHMEIER, JACLYN (SLP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:BACHMEIER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5160 44TH AVE S APT 301
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4000
Mailing Address - Country:US
Mailing Address - Phone:701-341-6025
Mailing Address - Fax:
Practice Address - Street 1:4725 AMBER VALLEY PKWY S STE B
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8614
Practice Address - Country:US
Practice Address - Phone:701-478-0221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1573235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1472212Medicaid