Healthcare Provider Details

I. General information

NPI: 1154239366
Provider Name (Legal Business Name): MISTY ANN JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2026
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4022 S CABOT RD
CARPENTER WY
82054-9611
US

IV. Provider business mailing address

4022 S CABOT RD
CARPENTER WY
82054-9611
US

V. Phone/Fax

Practice location:
  • Phone: 307-287-0818
  • Fax:
Mailing address:
  • Phone: 307-287-0818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: