Healthcare Provider Details

I. General information

NPI: 1033485214
Provider Name (Legal Business Name): JACLYN KATE ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2012
Last Update Date: 08/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N7770 LOYALTY RD
BLANCHARDVILLE WI
53516-9624
US

IV. Provider business mailing address

N7770 LOYALTY RD
BLANCHARDVILLE WI
53516-9624
US

V. Phone/Fax

Practice location:
  • Phone: 608-214-0173
  • Fax:
Mailing address:
  • Phone: 608-214-0173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number314220031
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number191453-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: