Provider Demographics
NPI:1598369514
Name:SKILLMAN, JACKIE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:SKILLMAN
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 1:2786 E US HIGHWAY 36
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:IN
Mailing Address - Zip Code:46105-9557
Mailing Address - Country:US
Mailing Address - Phone:765-721-4240
Mailing Address - Fax:
Practice Address - Street 1:10234 E US HIGHWAYS 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123
Practice Address - Country:US
Practice Address - Phone:317-207-0922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INF08201103363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily