Basic Information
| Provider Information | |||||||||
| NPI: | 1861928111 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGG | ||||||||
| FirstName: | JACKLYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | AGACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 277381 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303847381 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3100 CHANNING WAY | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085296111 | ||||||||
| FaxNumber: | 2085297021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2017 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | AP 60730619 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | 66593 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.