Healthcare Provider Details

I. General information

NPI: 1124797378
Provider Name (Legal Business Name): JACLYN NYSTROM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACLYN LOHMAN

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11807 ALLISONVILLE RD # 522
FISHERS IN
46038-2313
US

IV. Provider business mailing address

14512 BRECON LN
CARMEL IN
46074-6042
US

V. Phone/Fax

Practice location:
  • Phone: 317-572-5315
  • Fax:
Mailing address:
  • Phone: 317-697-4738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number95001491A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-71865
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: