Provider Demographics
NPI:1598927014
Name:MISKULIN-BAGGESEN, JACLYNN ANN (RN)
Entity Type:Individual
Prefix:MRS
First Name:JACLYNN
Middle Name:ANN
Last Name:MISKULIN-BAGGESEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2134 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-4569
Mailing Address - Country:US
Mailing Address - Phone:262-637-3179
Mailing Address - Fax:262-637-3179
Practice Address - Street 1:2134 GREEN ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-4569
Practice Address - Country:US
Practice Address - Phone:262-637-3179
Practice Address - Fax:262-637-3179
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI127497030163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38231000OtherWISCONSIN MEDICAID PROVIDER NUMBER