Provider Demographics
NPI:1578573382
Name:THOMAS, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:RUCKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:100 15TH AVE
Mailing Address - Street 2:#180
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-1160
Mailing Address - Country:US
Mailing Address - Phone:414-768-5430
Mailing Address - Fax:414-762-4225
Practice Address - Street 1:4202 W. OAKWOOD PARK CT.
Practice Address - Street 2:STE 200
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-9565
Practice Address - Country:US
Practice Address - Phone:414-423-5250
Practice Address - Fax:414-423-5256
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35632208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32207000Medicaid
WI02120-0325Medicare PIN