Provider Demographics
NPI:1952180218
Name:JACKS, WHITNEY WICKSTROM (DAOM)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:WICKSTROM
Last Name:JACKS
Suffix:
Gender:F
Credentials:DAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 LARSSON ST
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-6734
Mailing Address - Country:US
Mailing Address - Phone:310-955-6119
Mailing Address - Fax:
Practice Address - Street 1:1528 US HIGHWAY 395 N STE 230
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5226
Practice Address - Country:US
Practice Address - Phone:775-783-4930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist