Provider Demographics
NPI:1821236506
Name:VAN VLEET, JENNIFER L (RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:VAN VLEET
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N2348 COUNTY ROAD F
Mailing Address - Street 2:
Mailing Address - City:WALWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:53184-5662
Mailing Address - Country:US
Mailing Address - Phone:262-728-6648
Mailing Address - Fax:
Practice Address - Street 1:N2348 COUNTY ROAD F
Practice Address - Street 2:
Practice Address - City:WALWORTH
Practice Address - State:WI
Practice Address - Zip Code:53184-5662
Practice Address - Country:US
Practice Address - Phone:262-728-6648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163912-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse