Provider Demographics
NPI:1437646338
Name:KEATING, JACQUELINE LEIGH
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LEIGH
Last Name:KEATING
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 1:1200 SHAWNEE ST
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-3046
Mailing Address - Country:US
Mailing Address - Phone:920-222-9620
Mailing Address - Fax:
Practice Address - Street 1:2100 MAIN ST
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-3871
Practice Address - Country:US
Practice Address - Phone:715-346-2616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program