Provider Demographics
NPI:1669477071
Name:JENISON, ERIC L (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:L
Last Name:JENISON
Suffix:
Gender:M
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:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:704 S WEBSTER AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3528
Practice Address - Country:US
Practice Address - Phone:920-433-3430
Practice Address - Fax:920-432-6313
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH038252207V00000X
WI59856207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0288531Medicaid
WI1669477071Medicaid
OR0288531Medicaid
WI1669477071Medicaid
WI000000215Medicare Oscar/Certification