Provider Demographics
NPI:1669891099
Name:HARDENBROOK, JACQUELIN FOSS (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELIN
Middle Name:FOSS
Last Name:HARDENBROOK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUI
Other - Middle Name:
Other - Last Name:FOSS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 4182
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-4182
Mailing Address - Country:US
Mailing Address - Phone:307-733-6520
Mailing Address - Fax:801-662-5755
Practice Address - Street 1:555 E BROADWAY AVE STE 202
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-733-6520
Practice Address - Fax:307-733-3216
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WY11023A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program