Healthcare Provider Details

I. General information

NPI: 1770298366
Provider Name (Legal Business Name): KATRINA JABLONSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 W GARLAND ST
JEFFERSON WI
53549-2029
US

IV. Provider business mailing address

152 W GARLAND ST
JEFFERSON WI
53549-2029
US

V. Phone/Fax

Practice location:
  • Phone: 920-541-3773
  • Fax:
Mailing address:
  • Phone: 920-541-3773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number0019099
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: