Healthcare Provider Details

I. General information

NPI: 1669229720
Provider Name (Legal Business Name): JAKE DEGROOT RN, MSN, FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 N MEADE ST
APPLETON WI
54911-3454
US

IV. Provider business mailing address

5680 N AMETHYST DR
APPLETON WI
54913-7743
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-8900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number15326-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: