Provider Demographics
NPI:1326691254
Name:RIETZ, JACKIE MARIE (APNP, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:MARIE
Last Name:RIETZ
Suffix:
Gender:F
Credentials:APNP, FNP-C
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:MARIE
Other - Last Name:CORVINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11825 STATE ROUTE 40 STE 100
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-8842
Mailing Address - Country:US
Mailing Address - Phone:715-892-0616
Mailing Address - Fax:
Practice Address - Street 1:413 N 17TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4287
Practice Address - Country:US
Practice Address - Phone:715-298-4454
Practice Address - Fax:715-802-8568
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9354-33363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily