Provider Demographics
NPI:1710586235
Name:PADJEN, JACKELYN LAURA (NP)
Entity Type:Individual
Prefix:
First Name:JACKELYN
Middle Name:LAURA
Last Name:PADJEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JACKELYN
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:719 W HAMILTON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6970
Mailing Address - Country:US
Mailing Address - Phone:715-552-9784
Mailing Address - Fax:715-835-6370
Practice Address - Street 1:3213 STEIN BLVD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6946
Practice Address - Country:US
Practice Address - Phone:715-830-0732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7779363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily