Provider Demographics
NPI:1053519918
Name:JACKSON WHOLE FAMILY HEALTH, INC.
Entity type:Organization
Organization Name:JACKSON WHOLE FAMILY HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:OCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-733-7003
Mailing Address - Street 1:PO BOX 10738
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-0738
Mailing Address - Country:US
Mailing Address - Phone:307-733-7003
Mailing Address - Fax:307-734-8477
Practice Address - Street 1:1110 MAPLE WAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-7003
Practice Address - Fax:307-734-8477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY00581001OtherBLUE CROSS
WY00581001OtherBLUE CROSS