Provider Demographics
NPI:1679191043
Name:POTRATZ, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:POTRATZ
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:N52W15941 BETTE DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-0604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 W SUNSET DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189-8423
Practice Address - Country:US
Practice Address - Phone:262-832-1273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-11
Last Update Date:2020-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18926-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI18926-40OtherLICENSE