| Doctor Name: | JODI L SPACE |
| NPI Number: | 1518217280 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | APNP |
| License Number: | 5012-33 |
| Business Practice Address: | 5416 Everybodys Rd Crandon, WI - 545208627 |
| Business Phone Number: | 7154784890 |
| Business Fax Number: | |
| Mailing Address: | 5416 Everybodys Rd, CRANDON |
| State: | WI |
| Postal Code: | 545208627 |
| Phone Number: | 7154784890 |
| Fax Number: | |
| NPI Enumeration Date: | 09/10/2012 |
| NPI Last Update Date: | 09/10/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LP0808X |
| License Number: | 5012-33 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Psych/Mental Health |
| Taxonomy Definition: | |