Provider Demographics
NPI:1861822447
Name:ROGERS, JACKIE (RN)
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:KAY
Other - Last Name:POLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 348
Mailing Address - Street 2:
Mailing Address - City:HAZELHURST
Mailing Address - State:WI
Mailing Address - Zip Code:54531-0348
Mailing Address - Country:US
Mailing Address - Phone:715-892-8371
Mailing Address - Fax:
Practice Address - Street 1:9435 S. MILL RD.
Practice Address - Street 2:
Practice Address - City:HAZELHURST
Practice Address - State:WI
Practice Address - Zip Code:54531-0348
Practice Address - Country:US
Practice Address - Phone:715-892-8371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI77271-30163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health