Healthcare Provider Details

I. General information

NPI: 1467357533
Provider Name (Legal Business Name): CARLEEN JACKLOVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

2100 S 12TH ST APT 103
BISMARCK ND
58504-7483
US

IV. Provider business mailing address

2100 S 12TH ST APT 103
BISMARCK ND
58504-7483
US

V. Phone/Fax

Practice location:
  • Phone: 701-429-8308
  • Fax:
Mailing address:
  • Phone: 701-429-8308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: