Provider Demographics
NPI:1053619387
Name:SAILO, JACKLIN A (FNP)
Entity type:Individual
Prefix:
First Name:JACKLIN
Middle Name:A
Last Name:SAILO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 MISH KO SWEN DR
Mailing Address - Street 2:P.O. BOX 396
Mailing Address - City:CRANDON
Mailing Address - State:WI
Mailing Address - Zip Code:54520-8631
Mailing Address - Country:US
Mailing Address - Phone:715-478-4300
Mailing Address - Fax:
Practice Address - Street 1:8201 MISH KO SWEN DR
Practice Address - Street 2:
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520-8631
Practice Address - Country:US
Practice Address - Phone:715-478-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-10
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704225343363L00000X
WI4300-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP01015484OtherRR MEDICARE
WI1053619387Medicaid
MI0871496OtherBCBS OF MI
WI1053619387Medicaid
MIP01015484OtherRR MEDICARE