Basic Information
| Provider Information | |||||||||
| NPI: | 1336510635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAKSICH | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HAWKINS DRIVE | ||||||||
| Address2: | NEUROLOGY CLINIC | ||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193537131 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 HAYDEN BRIDGE WAY | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974771347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418689430 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2015 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | H124117 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | 202004567NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | R222420 | 05 | OR | MEDICAID |