Provider Demographics
NPI:1053756973
Name:TAKACH, JESSICA LYNN (APNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:TAKACH
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:DLAPA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:1000 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:715-387-5511
Mailing Address - Fax:
Practice Address - Street 1:1200 PORT ARTHUR RD
Practice Address - Street 2:
Practice Address - City:LADYSMITH
Practice Address - State:WI
Practice Address - Zip Code:54848-1137
Practice Address - Country:US
Practice Address - Phone:715-532-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5295-33363L00000X
WI5295363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100029838Medicaid
WI2012006772OtherFNP-BC
WIK400112181Medicare PIN