Healthcare Provider Details

I. General information

NPI: 1447164298
Provider Name (Legal Business Name): JESSICA LAKE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 10TH ST LOT 27
MENOMINEE MI
49858-1662
US

IV. Provider business mailing address

3400 10TH ST LOT 27
MENOMINEE MI
49858-1662
US

V. Phone/Fax

Practice location:
  • Phone: 906-235-1830
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1110017-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: