MEDICARE: BAYLEE LYN JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker

General Provider Information

NPI Number	:	1972247179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BAYLEE LYN JACKSON

Provider Business Mailing Address
First Line	:	PO BOX 1003
Second Line	:
City	:	MOUNTAIN VIEW
State	:	WY
Zip	:	82939-1003
Country	:	US
Telephone Number	:	307-747-7586
Fax Number	:

Provider Business Practice Location Address
First Line	:	849 FRONT ST STE 103
Second Line	:
City	:	EVANSTON
State	:	WY
Zip	:	82930-3475
Country	:	US
Telephone Number	:	307-444-5760
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2022
Last Update Date	:	06/18/2024

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