Provider Demographics
NPI:1275189508
Name:SPAGNOLETTI, JACKLYN ELAINE
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:ELAINE
Last Name:SPAGNOLETTI
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 1:187 WOLFORD AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:42539-3278
Mailing Address - Country:US
Mailing Address - Phone:606-787-6275
Mailing Address - Fax:606-787-0251
Practice Address - Street 1:CASEY COUNTY PRIMARY CARE
Practice Address - Street 2:187 WOLFORD AVENUE
Practice Address - City:LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:42539-3278
Practice Address - Country:US
Practice Address - Phone:606-787-8348
Practice Address - Fax:606-787-0251
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013711363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner