Provider Demographics
NPI:1740887405
Name:HINER, JACQUELINE RAE
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:RAE
Last Name:HINER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JACKIE
Other - Middle Name:RAE
Other - Last Name:HINER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:117 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:CO
Mailing Address - Zip Code:81052-2701
Mailing Address - Country:US
Mailing Address - Phone:719-691-1941
Mailing Address - Fax:719-691-2132
Practice Address - Street 1:117 W ELM ST
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:CO
Practice Address - Zip Code:81052-2701
Practice Address - Country:US
Practice Address - Phone:719-691-1941
Practice Address - Fax:719-691-2132
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO04S685253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO30854369Medicaid