Provider Demographics
NPI:1225281264
Name:JACKAN, JENNIFER R (APNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:JACKAN
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 E CAPITOL DR
Mailing Address - Street 2:SUITE 2600
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8735
Mailing Address - Country:US
Mailing Address - Phone:920-739-3537
Mailing Address - Fax:920-739-4115
Practice Address - Street 1:2500 E CAPITOL DR
Practice Address - Street 2:SUITE 2600
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8735
Practice Address - Country:US
Practice Address - Phone:920-739-3537
Practice Address - Fax:920-739-4115
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3460363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI141649-030OtherLICENSE
WI3460-033OtherWISCONSIN LICENSE NURSE PRACTITIONER
WI1225281264Medicaid
WI1225281264Medicaid
WI141649-030OtherLICENSE
WIW12072002Medicare PIN