Provider Demographics
NPI:1205277456
Name:JCKM, LLC ABBE C FANNIN SOLE MBR
Entity type:Organization
Organization Name:JCKM, LLC ABBE C FANNIN SOLE MBR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ABBE
Authorized Official - Middle Name:C
Authorized Official - Last Name:FANNIN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:765-284-0493
Mailing Address - Street 1:PO BOX 41
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47308-0041
Mailing Address - Country:US
Mailing Address - Phone:765-284-0493
Mailing Address - Fax:765-284-2434
Practice Address - Street 1:1416 GEORGE DIETER DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7601
Practice Address - Country:US
Practice Address - Phone:915-849-5104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-16
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX647336367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty