Provider Demographics
NPI:1477074144
Name:MAYER, JENESSA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENESSA
Middle Name:MARIE
Last Name:MAYER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 S 1ST ST UNIT 327
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-2477
Mailing Address - Country:US
Mailing Address - Phone:920-207-3802
Mailing Address - Fax:
Practice Address - Street 1:4701 SANGAMORE RD STE N270
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20816-2528
Practice Address - Country:US
Practice Address - Phone:414-955-6920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4046-23363A00000X
MDC0008549363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant