Provider Demographics
NPI:1598351173
Name:YAKICH, JORDAN ROBERT
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ROBERT
Last Name:YAKICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7833 STATE ROAD 38
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:WI
Mailing Address - Zip Code:53108-9607
Mailing Address - Country:US
Mailing Address - Phone:262-853-6947
Mailing Address - Fax:
Practice Address - Street 1:12800 N LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2418
Practice Address - Country:US
Practice Address - Phone:262-853-6947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2279E0002X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No2279E0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredEmergency Care