Provider Demographics
NPI:1306286612
Name:LUECK, JODY (LPN)
Entity type:Individual
Prefix:MRS
First Name:JODY
Middle Name:
Last Name:LUECK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 N HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54937-1846
Mailing Address - Country:US
Mailing Address - Phone:920-979-4154
Mailing Address - Fax:
Practice Address - Street 1:520 N HICKORY ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-1846
Practice Address - Country:US
Practice Address - Phone:920-979-4154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI304384-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse