Provider Demographics
NPI:1124542535
Name:HESEBECK, KENDRA E (PA)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:E
Last Name:HESEBECK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:E
Other - Last Name:JEFFERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:709 SPRING VALLEY RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-7614
Practice Address - Country:US
Practice Address - Phone:262-434-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4104363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100069467Medicaid