Provider Demographics
NPI:1912688284
Name:POHL, JACKIE SUE (LPN)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:SUE
Last Name:POHL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15945 WOOD RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906-1746
Mailing Address - Country:US
Mailing Address - Phone:517-394-1234
Mailing Address - Fax:
Practice Address - Street 1:15945 WOOD RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48906-1746
Practice Address - Country:US
Practice Address - Phone:517-394-1234
Practice Address - Fax:517-394-7716
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703086682164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse