Provider Demographics
NPI:1518217280
Name:SPACE, JODI L (APNP)
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:L
Last Name:SPACE
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5416 EVERYBODYS RD
Mailing Address - Street 2:
Mailing Address - City:CRANDON
Mailing Address - State:WI
Mailing Address - Zip Code:54520-8627
Mailing Address - Country:US
Mailing Address - Phone:715-478-4890
Mailing Address - Fax:
Practice Address - Street 1:5416 EVERYBODYS RD
Practice Address - Street 2:
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520-8627
Practice Address - Country:US
Practice Address - Phone:715-478-4890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5012363L00000X
WI5012-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner