Provider Demographics
NPI:1033577762
Name:HAEBERLE, JENNA RUTH (APRN, CNM)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:RUTH
Last Name:HAEBERLE
Suffix:
Gender:F
Credentials:APRN, CNM
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:RUTH
Other - Last Name:PETERSDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 778789
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8789
Mailing Address - Country:US
Mailing Address - Phone:414-672-1353
Mailing Address - Fax:
Practice Address - Street 1:1032 S CESAR E CHAVEZ DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-2203
Practice Address - Country:US
Practice Address - Phone:414-672-1353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-09
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI149030-32367A00000X
IL209.013259367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100204747Medicaid