Provider Demographics
NPI:1164502241
Name:VOLLRATH-GROSAM, JENNIFER L (BS, DC, FICPA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:VOLLRATH-GROSAM
Suffix:
Gender:F
Credentials:BS, DC, FICPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11067
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-1067
Mailing Address - Country:US
Mailing Address - Phone:920-434-2221
Mailing Address - Fax:920-434-2483
Practice Address - Street 1:721 CARDINAL LN
Practice Address - Street 2:STE 100
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-3216
Practice Address - Country:US
Practice Address - Phone:920-434-2221
Practice Address - Fax:920-434-2483
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3015111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38897900Medicaid
WI38897900Medicaid
WI270970Medicare ID - Type Unspecified