Provider Demographics
NPI:1508535360
Name:POLACEK, JENNIFER GAYLE (APNP-BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GAYLE
Last Name:POLACEK
Suffix:
Gender:F
Credentials:APNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W1692 FAWN AVE
Mailing Address - Street 2:
Mailing Address - City:RIB LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54470-9615
Mailing Address - Country:US
Mailing Address - Phone:715-560-0193
Mailing Address - Fax:
Practice Address - Street 1:729 PINE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:WI
Practice Address - Zip Code:54411-9305
Practice Address - Country:US
Practice Address - Phone:715-257-1686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11270-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner