Provider Demographics
NPI:1528486073
Name:JAKLICH, STEPHANIE (DH)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:JAKLICH
Suffix:
Gender:F
Credentials:DH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 1ST STREET
Mailing Address - Street 2:
Mailing Address - City:LIMON
Mailing Address - State:CO
Mailing Address - Zip Code:80828
Mailing Address - Country:US
Mailing Address - Phone:719-775-0300
Mailing Address - Fax:
Practice Address - Street 1:820 1ST STREET
Practice Address - Street 2:
Practice Address - City:LIMON
Practice Address - State:CO
Practice Address - Zip Code:80828
Practice Address - Country:US
Practice Address - Phone:719-775-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2871124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO2871OtherLICENSE