Provider Demographics
NPI:1043685860
Name:TAYLOR, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8716 S WOOD CREEK DR APT 1
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-7507
Mailing Address - Country:US
Mailing Address - Phone:414-439-4997
Mailing Address - Fax:
Practice Address - Street 1:8716 S WOOD CREEK DR APT 1
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-7507
Practice Address - Country:US
Practice Address - Phone:414-439-4997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI311064164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse