Provider Demographics
NPI:1841462462
Name:JACKIE N. WYLAND
Entity type:Organization
Organization Name:JACKIE N. WYLAND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:WYLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-695-1801
Mailing Address - Street 1:RD 1 BOX 147 A
Mailing Address - Street 2:
Mailing Address - City:EAST FREEDOM
Mailing Address - State:PA
Mailing Address - Zip Code:16637-9731
Mailing Address - Country:US
Mailing Address - Phone:814-695-1801
Mailing Address - Fax:814-695-7074
Practice Address - Street 1:RD 1 BOX 147 A
Practice Address - Street 2:DEVECCHIS ST MCKEE
Practice Address - City:EAST FREEDOM
Practice Address - State:PA
Practice Address - Zip Code:16637
Practice Address - Country:US
Practice Address - Phone:814-695-1801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS021195L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty