Provider Demographics
NPI:1245774181
Name:REICHELT, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:REICHELT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W5073 GOLF DR
Mailing Address - Street 2:
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452-9254
Mailing Address - Country:US
Mailing Address - Phone:715-216-9495
Mailing Address - Fax:
Practice Address - Street 1:425 PINE RIDGE BLVD STE 211
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4123
Practice Address - Country:US
Practice Address - Phone:715-845-5505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR2207102163W00000X
390200000X
MNR-220710-2367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program