Provider Demographics
NPI:1902995251
Name:MOE, JACQUELINE SUSAN (APNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SUSAN
Last Name:MOE
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 970
Mailing Address - Street 2:
Mailing Address - City:KESHENA
Mailing Address - State:WI
Mailing Address - Zip Code:54135-0970
Mailing Address - Country:US
Mailing Address - Phone:715-799-3361
Mailing Address - Fax:715-799-5854
Practice Address - Street 1:W3275 WOLF RIVER DR
Practice Address - Street 2:
Practice Address - City:KESHENA
Practice Address - State:WI
Practice Address - Zip Code:54135-9202
Practice Address - Country:US
Practice Address - Phone:715-799-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2966-033363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36015400Medicaid
WI000195Medicare Oscar/Certification
WI000034Medicare Oscar/Certification
WI000025Medicare Oscar/Certification