Provider Demographics
NPI:1992405013
Name:BIRCHEM, JACKLYN MARIE
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:MARIE
Last Name:BIRCHEM
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 1:1321 17TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3934
Mailing Address - Country:US
Mailing Address - Phone:701-308-0801
Mailing Address - Fax:
Practice Address - Street 1:1321 17TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3934
Practice Address - Country:US
Practice Address - Phone:701-308-0801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant