Healthcare Provider Details

I. General information

NPI: 1952180218
Provider Name (Legal Business Name): WHITNEY WICKSTROM JACKS DAOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2023
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 US HIGHWAY 395 N STE 230
GARDNERVILLE NV
89410-5226
US

IV. Provider business mailing address

505 LARSSON ST
MANHATTAN BEACH CA
90266-6734
US

V. Phone/Fax

Practice location:
  • Phone: 775-783-4930
  • Fax:
Mailing address:
  • Phone: 310-955-6119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: