Provider Demographics
NPI:1982075701
Name:DES JARDINS, KATIE JEAN
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:JEAN
Last Name:DES JARDINS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 E NORTHLAND AVE STE B
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8582
Mailing Address - Country:US
Mailing Address - Phone:920-731-1999
Mailing Address - Fax:920-731-3729
Practice Address - Street 1:1301 E NORTHLAND AVE STE B
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8582
Practice Address - Country:US
Practice Address - Phone:920-731-1999
Practice Address - Fax:920-731-3729
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI247937-30163W00000X
WI1922-392255A2300X
WI14228-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer