Healthcare Provider Details

I. General information

NPI: 1114842945
Provider Name (Legal Business Name): JACKIE LEE WITTROCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5445 170TH ST
HOLSTEIN IA
51025-8053
US

IV. Provider business mailing address

5445 170TH ST
HOLSTEIN IA
51025-8053
US

V. Phone/Fax

Practice location:
  • Phone: 712-369-0344
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number139686
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: