Provider Demographics
NPI:1780010744
Name:LUECKE, JEFFREY (FNP)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:LUECKE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-389-2233
Mailing Address - Fax:
Practice Address - Street 1:130 W BRUCE ST
Practice Address - Street 2:200
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-1667
Practice Address - Country:US
Practice Address - Phone:414-384-1400
Practice Address - Fax:414-672-7012
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5508363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100034923Medicaid