Provider Demographics
NPI:1821261082
Name:JAKUBIEC, NANCY ANN (COTA)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:ANN
Last Name:JAKUBIEC
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MRS
Other - First Name:NANCY
Other - Middle Name:ANN
Other - Last Name:STEINKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:2961 ST ANTHONY DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311
Mailing Address - Country:US
Mailing Address - Phone:920-468-0861
Mailing Address - Fax:920-468-3087
Practice Address - Street 1:2961 SAINT ANTHONY DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-5860
Practice Address - Country:US
Practice Address - Phone:920-468-0861
Practice Address - Fax:920-468-3087
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI949-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40737200Medicaid