Individual
JILLIAN ANN HACKER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
ATC
Contact information
Practice address
3946 ICE WAY, FORT WAYNE, IN 46805-1018
(260) 444-2788
Mailing address
8813 GULF DR APT B, FORT WAYNE, IN 46825-3092
(765) 524-7455
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
36003377A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2000038863
BOC
IN
01
—
36003377A
INDIANA PROFESSIONAL LICENSING AGENCY
IN
Enumeration date
07/25/2018
Last updated
09/03/2020
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