Healthcare Provider Details

I. General information

NPI: 1003736539
Provider Name (Legal Business Name): JACQUELINE NAKOULMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE MIMI OUEDRAOGO

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 N 104TH PLZ APT 110
OMAHA NE
68134-7755
US

IV. Provider business mailing address

3930 N 104TH PLZ APT 110
OMAHA NE
68134-7755
US

V. Phone/Fax

Practice location:
  • Phone: 912-602-5133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number259448
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: