Healthcare Provider Details

I. General information

NPI: 1588598205
Provider Name (Legal Business Name): JACY RAE TODD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2090 US HIGHWAY 14
BANNER WY
82832-9709
US

IV. Provider business mailing address

2090 US HIGHWAY 14
BANNER WY
82832-9709
US

V. Phone/Fax

Practice location:
  • Phone: 307-620-5814
  • Fax:
Mailing address:
  • Phone: 307-620-5814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number47668
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: