Provider Demographics
NPI:1558601906
Name:NONE
Entity Type:Organization
Organization Name:NONE
Other - Org Name:NONE
Other - Org Type:Other Name
Authorized Official - Title/Position:REGISTERED NURSE
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:KSOBIECH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-241-7583
Mailing Address - Street 1:6058 ORIOLE LN
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6058 ORIOLE LN
Practice Address - Street 2:
Practice Address - City:GREENDALE
Practice Address - State:WI
Practice Address - Zip Code:53129-2552
Practice Address - Country:US
Practice Address - Phone:414-241-7583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI194720-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty