Provider Demographics
NPI:1093692550
Name:JACQUES, KYLIE (LM, CPM)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:JACQUES
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-2936
Mailing Address - Country:US
Mailing Address - Phone:701-412-7415
Mailing Address - Fax:
Practice Address - Street 1:990 PLANK RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-2936
Practice Address - Country:US
Practice Address - Phone:701-412-7415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI604-49176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife