Healthcare Provider Details

I. General information

NPI: 1487969572
Provider Name (Legal Business Name): JACKLYN M SPATES APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E GRANT ST SUITE 230
APPLETON WI
54911-3483
US

IV. Provider business mailing address

2500 OVERLOOK TER SUITE 230
MADISON WI
53705-2254
US

V. Phone/Fax

Practice location:
  • Phone: 920-738-7300
  • Fax: 920-738-7301
Mailing address:
  • Phone: 608-256-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: