Provider Demographics
NPI:1114475225
Name:WILLARD, JESSE (LPN)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:WILLARD
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 MORRAINE VIEW DR
Mailing Address - Street 2:UNIT 301
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-3078
Mailing Address - Country:US
Mailing Address - Phone:608-338-9774
Mailing Address - Fax:
Practice Address - Street 1:1128 MORRAINE VIEW DR
Practice Address - Street 2:UNIT 301
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-3078
Practice Address - Country:US
Practice Address - Phone:608-338-9774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-18
Last Update Date:2016-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI320697-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse