Healthcare Provider Details

I. General information

NPI: 1225676083
Provider Name (Legal Business Name): JACQUELYN LIETKE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2019
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 SOUTH AVE STE 105
LA CROSSE WI
54601-6720
US

IV. Provider business mailing address

3120 SOUTH AVE STE 105
LA CROSSE WI
54601-6720
US

V. Phone/Fax

Practice location:
  • Phone: 608-317-5788
  • Fax:
Mailing address:
  • Phone: 608-317-5788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number10111-146
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: