Provider Demographics
NPI:1770950628
Name:HARDMAN, JACKIE LYNNE
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNNE
Last Name:HARDMAN
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 1:11303 SKYLINE RD
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95436-9737
Mailing Address - Country:US
Mailing Address - Phone:707-820-1531
Mailing Address - Fax:
Practice Address - Street 1:634 PRESSLEY ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5526
Practice Address - Country:US
Practice Address - Phone:707-573-6955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1234OtherMEDICAL