Provider Demographics
NPI:1417185232
Name:KOSKI, JACQUELINE M (DO)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:KOSKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-4674
Mailing Address - Country:US
Mailing Address - Phone:920-215-0022
Mailing Address - Fax:
Practice Address - Street 1:163 E NORTH WATER ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2708
Practice Address - Country:US
Practice Address - Phone:920-215-0022
Practice Address - Fax:920-921-3500
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-01
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI59923-21207Q00000X, 207Q00000X
MI5101018350207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100028755Medicaid