Provider Demographics
NPI:1093058505
Name:JANZ VERNOSKI, JACEY LEANN
Entity Type:Individual
Prefix:MRS
First Name:JACEY
Middle Name:LEANN
Last Name:JANZ VERNOSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 LAKE SHORE DR E
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-2331
Mailing Address - Country:US
Mailing Address - Phone:715-685-6600
Mailing Address - Fax:715-685-6601
Practice Address - Street 1:2201 LAKE SHORE DR E
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806
Practice Address - Country:US
Practice Address - Phone:715-685-6600
Practice Address - Fax:715-685-6601
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1997-19225200000X
WI14170225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant