Provider Demographics
NPI:1356303101
Name:JEANNETTE PONDER
Entity Type:Organization
Organization Name:JEANNETTE PONDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN RCS
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:PONDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-447-1489
Mailing Address - Street 1:3152 N 24TH PL
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-1209
Mailing Address - Country:US
Mailing Address - Phone:414-447-1489
Mailing Address - Fax:
Practice Address - Street 1:3152 N 24TH PL
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-1209
Practice Address - Country:US
Practice Address - Phone:414-447-1489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI118183140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39973100Medicaid