Provider Demographics
NPI:1760966162
Name:SELNER, JERRY MICHAEL
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:MICHAEL
Last Name:SELNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N2526 COUNTY ROAD B
Mailing Address - Street 2:
Mailing Address - City:KEWAUNEE
Mailing Address - State:WI
Mailing Address - Zip Code:54216-9695
Mailing Address - Country:US
Mailing Address - Phone:920-388-0225
Mailing Address - Fax:
Practice Address - Street 1:N2526 COUNTY ROAD B
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216-9695
Practice Address - Country:US
Practice Address - Phone:920-388-0225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications