Provider Demographics
NPI:1306303797
Name:BAHHO, JACKLIN YAKKEN
Entity type:Individual
Prefix:
First Name:JACKLIN
Middle Name:YAKKEN
Last Name:BAHHO
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 1:29038 HEARTHSTONE DR
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2724
Mailing Address - Country:US
Mailing Address - Phone:757-755-5031
Mailing Address - Fax:
Practice Address - Street 1:29038 HEARTHSTONE DR
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2724
Practice Address - Country:US
Practice Address - Phone:757-755-5031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703120576164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse