Provider Demographics
NPI:1710611074
Name:HENNIG, JESSICA (RDH)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HENNIG
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FAMILY HEALTH LA CLINICA
Mailing Address - Street 2:400 S. TOWNLINE RD.
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982
Mailing Address - Country:US
Mailing Address - Phone:920-787-5514
Mailing Address - Fax:920-787-4737
Practice Address - Street 1:880 HERRIOT DR
Practice Address - Street 2:
Practice Address - City:MAUSTON
Practice Address - State:WI
Practice Address - Zip Code:53948-2031
Practice Address - Country:US
Practice Address - Phone:608-847-6700
Practice Address - Fax:608-847-6122
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1003469124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist