Healthcare Provider Details

I. General information

NPI: 1205742004
Provider Name (Legal Business Name): MRS. JENNIFER MARY BACA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER MARY CLANACHAN

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2028 OMAHA TRL
BAR NUNN WY
82601-7603
US

IV. Provider business mailing address

2028 OMAHA TRL
BAR NUNN WY
82601-7603
US

V. Phone/Fax

Practice location:
  • Phone: 307-262-6150
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number1695T
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: