Provider Demographics
NPI:1164620480
Name:MCLELLAN, JENNIFER A (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:A
Last Name:MCLELLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:610 E TAYLOR ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU CHIEN
Practice Address - State:WI
Practice Address - Zip Code:53821-2109
Practice Address - Country:US
Practice Address - Phone:608-326-6466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-08
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090378208600000X
MA250712208600000X
IA41119208600000X
WI61061208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery