Basic Information
| Provider Information | |||||||||
| NPI: | 1104183516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JANDRIN | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BARTZ | ||||||||
| OtherFirstName: | LACEY | ||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 164 N BROADWAY | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543032728 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1160 KEPLER DR | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543118321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202885555 | ||||||||
| FaxNumber: | 9202885550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2012 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 4712 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 363A00000X | 1135070 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.