Provider Demographics
NPI:1568040541
Name:MAYVILLE, JESSICA J
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:J
Last Name:MAYVILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2690 HUMBOLDT RD APT 7
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2517 N VIEW CT
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-6233
Practice Address - Country:US
Practice Address - Phone:920-494-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator