Provider Demographics
NPI:1376883397
Name:KIERNICKI, JARED WILLIAM (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JARED
Middle Name:WILLIAM
Last Name:KIERNICKI
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-2789
Practice Address - Street 1:1970 S RIDGE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-4125
Practice Address - Country:US
Practice Address - Phone:920-430-4888
Practice Address - Fax:920-430-4889
Is Sole Proprietor?:No
Enumeration Date:2013-02-28
Last Update Date:2021-06-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KYPA2286363A00000X
IN10002329A363A00000X
WI5235-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant