Provider Demographics
NPI:1639863038
Name:AMENDT, JERICKA LEE (SPECIALISTS A14042)
Entity Type:Individual
Prefix:
First Name:JERICKA
Middle Name:LEE
Last Name:AMENDT
Suffix:
Gender:F
Credentials:SPECIALISTS A14042
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 DEERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7734
Mailing Address - Country:US
Mailing Address - Phone:612-325-4470
Mailing Address - Fax:
Practice Address - Street 1:67 DEERWOOD CT
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7734
Practice Address - Country:US
Practice Address - Phone:612-325-4470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist