Healthcare Provider Details

I. General information

NPI: 1699066118
Provider Name (Legal Business Name): JACLYN JOY WEBSTER R.N., BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACLYN JOY GONSIOREK RN, BSN

II. Dates (important events)

Enumeration Date: 05/02/2011
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 MALLARD LN
GENOA CITY WI
53128-1995
US

IV. Provider business mailing address

1007 MALLARD LN
GENOA CITY WI
53128-1995
US

V. Phone/Fax

Practice location:
  • Phone: 262-227-3191
  • Fax:
Mailing address:
  • Phone: 262-227-3191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number177049030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: