Provider Demographics
NPI:1922545169
Name:PANNEBAKKER, JACQUELIN
Entity Type:Individual
Prefix:
First Name:JACQUELIN
Middle Name:
Last Name:PANNEBAKKER
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 1:765 S LAFAYETTE DR APT 152
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-3568
Mailing Address - Country:US
Mailing Address - Phone:717-943-5808
Mailing Address - Fax:
Practice Address - Street 1:12123 E 16TH AVENUE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045
Practice Address - Country:US
Practice Address - Phone:720-777-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0013703225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant