Provider Demographics
NPI:1740436286
Name:WALGRAM, JACKIE (RN/HEALTH EDUCATOR)
Entity type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:
Last Name:WALGRAM
Suffix:
Gender:F
Credentials:RN/HEALTH EDUCATOR
Other - Prefix:MS
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:HOWARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4881 WIL O PAW DR
Mailing Address - Street 2:
Mailing Address - City:COLOMA
Mailing Address - State:MI
Mailing Address - Zip Code:49038-8816
Mailing Address - Country:US
Mailing Address - Phone:269-569-4509
Mailing Address - Fax:
Practice Address - Street 1:4881 WIL O PAW DR
Practice Address - Street 2:
Practice Address - City:COLOMA
Practice Address - State:MI
Practice Address - Zip Code:49038-8816
Practice Address - Country:US
Practice Address - Phone:269-325-5659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-15
Last Update Date:2019-08-14
Deactivation Date:2019-07-01
Deactivation Code:
Reactivation Date:2019-07-11
Provider Licenses
StateLicense IDTaxonomies
MI4704132716174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704132716OtherLICENSE