Provider Demographics
NPI:1477116523
Name:PROHUSKA, JESSICA D (LAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:D
Last Name:PROHUSKA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 HAZEL RIDGE RD APT 305
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-1251
Mailing Address - Country:US
Mailing Address - Phone:262-475-9661
Mailing Address - Fax:
Practice Address - Street 1:3278 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST TROY
Practice Address - State:WI
Practice Address - Zip Code:53120-1152
Practice Address - Country:US
Practice Address - Phone:262-642-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
WI993-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist