Provider Demographics
NPI:1013399047
Name:TOMASIEWICZ, JESSICA JO
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JO
Last Name:TOMASIEWICZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:JO
Other - Last Name:WILKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 8003
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-8003
Mailing Address - Country:US
Mailing Address - Phone:920-830-5900
Mailing Address - Fax:920-738-5787
Practice Address - Street 1:225 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1243
Practice Address - Country:US
Practice Address - Phone:920-361-5538
Practice Address - Fax:920-361-5499
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI164565-30367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered