Individual
LACEY L JANDRIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
1970 S RIDGE RD, GREEN BAY, WI 54304-4125
(920) 430-4888
(920) 430-4889
Mailing address
PO BOX 22487, GREEN BAY, WI 54305-2487
(920) 445-7210
(920) 445-7289
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
4712
WI
363A00000X
Physician Assistant
1135070
WI
363A00000X
Physician Assistant
Primary
3761-23
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1135070
NATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS
—
Enumeration date
04/23/2012
Last updated
01/30/2023
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