Healthcare Provider Details

I. General information

NPI: 1952714107
Provider Name (Legal Business Name): JESSICA PANEK ASSOCIATE DEGREE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA KOBY

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SOUTH AVE
LA CROSSE WI
54601-5467
US

IV. Provider business mailing address

1900 SOUTH AVE
LA CROSSE WI
54601-5467
US

V. Phone/Fax

Practice location:
  • Phone: 86-775-3462
  • Fax:
Mailing address:
  • Phone: 86-775-3462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number199436
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: