Provider Demographics
NPI:1518298033
Name:ANDERSON, JENNIFER R (RN, BSN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 W MARTIN DR APT 4
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-2755
Mailing Address - Country:US
Mailing Address - Phone:414-455-3286
Mailing Address - Fax:
Practice Address - Street 1:4141 W MARTIN DR APT 4
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-2755
Practice Address - Country:US
Practice Address - Phone:414-455-3286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI159696163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse