Provider Demographics
NPI:1225676083
Name:LIETKE, JACQUELYN (LMT)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:LIETKE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 SOUTH AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-6720
Mailing Address - Country:US
Mailing Address - Phone:608-317-5788
Mailing Address - Fax:
Practice Address - Street 1:3120 SOUTH AVE STE 105
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-6720
Practice Address - Country:US
Practice Address - Phone:608-317-5788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI225700000X
WI10111-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty