Provider Demographics
NPI:1689200743
Name:GAGO, JENNIFER MARIA
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIA
Last Name:GAGO
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:W6810 FALCON AVE
Mailing Address - Street 2:
Mailing Address - City:TONY
Mailing Address - State:WI
Mailing Address - Zip Code:54563-9713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6480 TECHNOLOGY AVE STE A
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-8126
Practice Address - Country:US
Practice Address - Phone:262-250-8009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI200314163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse