Provider Demographics
NPI:1396757688
Name:KEIM, JEAN L (NP)
Entity type:Individual
Prefix:MS
First Name:JEAN
Middle Name:L
Last Name:KEIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:JEAN
Other - Middle Name:L
Other - Last Name:PRENTICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:LUXEMBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54217-0099
Mailing Address - Country:US
Mailing Address - Phone:920-845-2351
Mailing Address - Fax:920-845-9001
Practice Address - Street 1:101 SCHOOL CREEK TRL
Practice Address - Street 2:
Practice Address - City:LUXEMBURG
Practice Address - State:WI
Practice Address - Zip Code:54217-1095
Practice Address - Country:US
Practice Address - Phone:920-845-2351
Practice Address - Fax:920-845-2001
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI421363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
R97980Medicare UPIN
0002-33050Medicare ID - Type Unspecified