Provider Demographics
NPI:1487496402
Name:JACKLEN, JEWELLE RUTH (ATC)
Entity type:Individual
Prefix:
First Name:JEWELLE
Middle Name:RUTH
Last Name:JACKLEN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11860 ZEA ST NW APT 306
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-6838
Mailing Address - Country:US
Mailing Address - Phone:763-218-5332
Mailing Address - Fax:
Practice Address - Street 1:11860 ZEA ST NW APT 306
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-6838
Practice Address - Country:US
Practice Address - Phone:763-218-5332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer