Provider Demographics
NPI:1841690732
Name:JACKNIN, ERICA (MA, ATR-BC, LPAT)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:JACKNIN
Suffix:
Gender:F
Credentials:MA, ATR-BC, LPAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SHERLOCK CT
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-6915
Mailing Address - Country:US
Mailing Address - Phone:303-929-5307
Mailing Address - Fax:
Practice Address - Street 1:100 SHERLOCK CT
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048
Practice Address - Country:US
Practice Address - Phone:303-929-5307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCAT0201081221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist