=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093058505
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. JACEY LEANN JANZ VERNOSKI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2013
-----------------------------------------------------
Last Update Date | 05/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2201 LAKE SHORE DR E
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-685-6600
-----------------------------------------------------
Fax | 715-685-6601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2201 LAKE SHORE DR E
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54806-2331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-685-6600
-----------------------------------------------------
Fax | 715-685-6601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 1997-19
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 14170
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------