Provider Demographics
NPI:1942502612
Name:JACKLEY, JENELL DIANE (CPNP)
Entity type:Individual
Prefix:MRS
First Name:JENELL
Middle Name:DIANE
Last Name:JACKLEY
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 BUCK TRL
Mailing Address - Street 2:
Mailing Address - City:TWIN LAKES
Mailing Address - State:WI
Mailing Address - Zip Code:53181-9637
Mailing Address - Country:US
Mailing Address - Phone:262-914-1433
Mailing Address - Fax:
Practice Address - Street 1:4006 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-4819
Practice Address - Country:US
Practice Address - Phone:262-656-0044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-30
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.389592163W00000X
WI163094-030163W00000X
IL209.010138363LP0200X
WI12260-33363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse