Basic Information
| Provider Information | |||||||||
| NPI: | 1669891099 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARDENBROOK | ||||||||
| FirstName: | JACQUELIN | ||||||||
| MiddleName: | FOSS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FOSS | ||||||||
| OtherFirstName: | JACQUI | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4182 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830014182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077336520 | ||||||||
| FaxNumber: | 8016625755 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 E BROADWAY AVE STE 202 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830018640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077336520 | ||||||||
| FaxNumber: | 3077333216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2014 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 11023A | WY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.