Healthcare Provider Details

I. General information

NPI: 1437062379
Provider Name (Legal Business Name): JACY KRUCKENBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 E 22ND ST
CHEYENNE WY
82001-4143
US

IV. Provider business mailing address

1900 E 22ND ST
CHEYENNE WY
82001-4143
US

V. Phone/Fax

Practice location:
  • Phone: 307-421-2679
  • Fax:
Mailing address:
  • Phone: 307-421-2679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: