Provider Demographics
NPI:1760941033
Name:LANDRY, JACQUELINE CHRISTINE (CSCS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:CHRISTINE
Last Name:LANDRY
Suffix:
Gender:F
Credentials:CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2027 LARKSPUR DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1054
Mailing Address - Country:US
Mailing Address - Phone:920-574-0558
Mailing Address - Fax:
Practice Address - Street 1:2050 4TH AVE
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-1910
Practice Address - Country:US
Practice Address - Phone:715-346-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-17
Last Update Date:2019-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program