Provider Demographics
NPI:1598795023
Name:LEACH, JENNIE A (MD)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:A
Last Name:LEACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 MAPLE ST
Mailing Address - Street 2:PO BOX 470
Mailing Address - City:WOODRUFF
Mailing Address - State:WI
Mailing Address - Zip Code:54568-0470
Mailing Address - Country:US
Mailing Address - Phone:715-356-8000
Mailing Address - Fax:
Practice Address - Street 1:240 MAPLE ST
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568-0470
Practice Address - Country:US
Practice Address - Phone:715-356-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41726-020207P00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34014300Medicaid
WI34014300Medicaid
WI0052-00483Medicare ID - Type UnspecifiedMEDICARE PART B