Provider Demographics
NPI:1124301023
Name:HACKBARTH, ROXANN JEAN
Entity type:Individual
Prefix:MRS
First Name:ROXANN
Middle Name:JEAN
Last Name:HACKBARTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:SUITE #3
Mailing Address - City:MILFORD
Mailing Address - State:IA
Mailing Address - Zip Code:51351-0207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1004 21ST ST
Practice Address - Street 2:SUITE #3
Practice Address - City:MILFORD
Practice Address - State:IA
Practice Address - Zip Code:51351-7421
Practice Address - Country:US
Practice Address - Phone:712-338-6911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG-092068363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health