Healthcare Provider Details

I. General information

NPI: 1093630030
Provider Name (Legal Business Name): JADE CYDNEI THOMASLACKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JADE CYDNEI DIOR THOMAS LACKEY

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 37TH AVE SE
MINOT ND
58701-6216
US

IV. Provider business mailing address

1321 37TH AVE SE
MINOT ND
58701-6216
US

V. Phone/Fax

Practice location:
  • Phone: 313-726-0590
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: