Provider Demographics
NPI:1033227517
Name:KEKKE, JOLYNN MARIE (PA)
Entity Type:Individual
Prefix:MS
First Name:JOLYNN
Middle Name:MARIE
Last Name:KEKKE
Suffix:
Gender:F
Credentials:PA
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 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:920-996-3200
Mailing Address - Fax:920-738-5787
Practice Address - Street 1:1516 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-4802
Practice Address - Country:US
Practice Address - Phone:920-725-0077
Practice Address - Fax:920-725-6535
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1262-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000771420Medicare ID - Type Unspecified
P19498Medicare UPIN