Provider Demographics
NPI:1174067359
Name:HAAK, JACLYN (IBCLC)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:HAAK
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 BROADWAY N
Mailing Address - Street 2:ROUTING #0110
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-3641
Mailing Address - Country:US
Mailing Address - Phone:701-234-6294
Mailing Address - Fax:
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:ROUTING #0110
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-6294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR31313163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant