Provider Demographics
NPI:1750457545
Name:NOSSE, JAN LUCAS
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:LUCAS
Last Name:NOSSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:ELIZABETH
Other - Last Name:LUCAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2345 N 114TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1225
Mailing Address - Country:US
Mailing Address - Phone:414-453-0135
Mailing Address - Fax:
Practice Address - Street 1:2345 N 114TH ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1225
Practice Address - Country:US
Practice Address - Phone:414-453-0135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1270225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40092200Medicaid