Healthcare Provider Details

I. General information

NPI: 1598351173
Provider Name (Legal Business Name): JORDAN ROBERT YAKICH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2020
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12800 N LAKE SHORE DR
MEQUON WI
53097-2418
US

IV. Provider business mailing address

7833 STATE ROAD 38
CALEDONIA WI
53108-9607
US

V. Phone/Fax

Practice location:
  • Phone: 262-853-6947
  • Fax:
Mailing address:
  • Phone: 262-853-6947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2279E0002X
TaxonomyEmergency Care Registered Respiratory Therapist
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: