1891790291 NPI number — MRS. JENNIFER JO HACKMAN P.T. ,A.T.C.

Table of content: ANNA DOSSO RPH (NPI 1649605593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891790291 NPI number — MRS. JENNIFER JO HACKMAN P.T. ,A.T.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HACKMAN
Provider First Name:
JENNIFER
Provider Middle Name:
JO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T. ,A.T.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891790291
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1420 W ASHLEY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOONVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65233-2112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
660-882-6115
Provider Business Mailing Address Fax Number:
660-882-6120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1420 W ASHLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOONVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65233-2112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-882-6115
Provider Business Practice Location Address Fax Number:
660-882-6120
Provider Enumeration Date:
06/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2002024893 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 122566 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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