Healthcare Provider Details

I. General information

NPI: 1497439806
Provider Name (Legal Business Name): JACKIE LYNN KALKHOFF LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 S CLARK ST STE 375
CARROLL IA
51401-3038
US

IV. Provider business mailing address

311 S CLARK ST STE 375
CARROLL IA
51401-3038
US

V. Phone/Fax

Practice location:
  • Phone: 712-794-6780
  • Fax: 712-792-7853
Mailing address:
  • Phone: 712-794-6780
  • Fax: 712-792-7853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberP27559
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: