Provider Demographics
NPI:1255698924
Name:BELISLE, JENNIFER ANNE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:BELISLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:HEBDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2600 65TH AVE
Mailing Address - Street 2:PO BOX 218
Mailing Address - City:OSCEOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54020-4370
Mailing Address - Country:US
Mailing Address - Phone:715-294-2111
Mailing Address - Fax:
Practice Address - Street 1:2600 65TH AVE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:WI
Practice Address - Zip Code:54020-4370
Practice Address - Country:US
Practice Address - Phone:715-294-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI63408207Q00000X
MN56486207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine