Provider Demographics
NPI:1710142112
Name:HOMM, JACIE
Entity Type:Individual
Prefix:
First Name:JACIE
Middle Name:
Last Name:HOMM
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 1:2322 SAN JUAN AVE
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-3341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2322 SAN JUAN AVE
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-3341
Practice Address - Country:US
Practice Address - Phone:719-383-3939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO905307124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO58300783Medicaid