Healthcare Provider Details

I. General information

NPI: 1033103833
Provider Name (Legal Business Name): JEANNE M LYKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEANNE M JAUCH

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 PARKSIDE ST
RIPON WI
54971-8505
US

IV. Provider business mailing address

420 E DIVISION ST
FOND DU LAC WI
54935-4560
US

V. Phone/Fax

Practice location:
  • Phone: 920-745-3560
  • Fax: 920-926-8370
Mailing address:
  • Phone: 920-926-8332
  • Fax: 920-926-8370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34644
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: