Provider Demographics
NPI:1104152875
Name:JACQUES, JANELL R (RN)
Entity type:Individual
Prefix:
First Name:JANELL
Middle Name:R
Last Name:JACQUES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 E PARIS WAY APT 8
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8298
Mailing Address - Country:US
Mailing Address - Phone:920-810-5027
Mailing Address - Fax:
Practice Address - Street 1:1981 GREENGROVE ST
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-3921
Practice Address - Country:US
Practice Address - Phone:920-759-4436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-30
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI311511-031164W00000X
WI218535163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse