Healthcare Provider Details

I. General information

NPI: 1073283362
Provider Name (Legal Business Name): JACLYNN MARIE THACKER APRN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W LONGEST ST
PAOLI IN
47454-8821
US

IV. Provider business mailing address

420 W LONGEST ST
PAOLI IN
47454-8821
US

V. Phone/Fax

Practice location:
  • Phone: 812-723-3944
  • Fax:
Mailing address:
  • Phone: 812-723-3944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71011761A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: