Provider Demographics
NPI:1215609482
Name:LAKE, JODI JAY (RN)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:JAY
Last Name:LAKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 E WARNIMONT AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-3572
Mailing Address - Country:US
Mailing Address - Phone:253-282-6692
Mailing Address - Fax:
Practice Address - Street 1:1522 E WARNIMONT AVE APT 1
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-3572
Practice Address - Country:US
Practice Address - Phone:253-282-6692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI81337163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse