Provider Demographics
NPI:1770647364
Name:KING, JENNIFER RAE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:KING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RAE
Other - Last Name:KING-VASSEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8200 W SILVER SPRING DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-2552
Mailing Address - Country:US
Mailing Address - Phone:414-267-8521
Mailing Address - Fax:414-464-6472
Practice Address - Street 1:8200 W SILVER SPRING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-2552
Practice Address - Country:US
Practice Address - Phone:414-267-8521
Practice Address - Fax:414-464-6472
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36971-0202084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32265200Medicaid
WIG51662Medicare UPIN