Provider Demographics
NPI:1033162078
Name:LUEDKE, JENNIFER ANNE (PAC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ANNE
Last Name:LUEDKE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:MIRENDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:601 N 99TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4339
Mailing Address - Country:US
Mailing Address - Phone:414-988-5100
Mailing Address - Fax:414-988-5102
Practice Address - Street 1:601 N 99TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4339
Practice Address - Country:US
Practice Address - Phone:414-988-5100
Practice Address - Fax:414-988-5102
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
028850001Medicare PIN
WIQ71591Medicare UPIN