Provider Demographics
NPI:1336764570
Name:MATTSON, JESSICA KATHLEEN (RN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KATHLEEN
Last Name:MATTSON
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 1:215 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN CITY
Mailing Address - State:WI
Mailing Address - Zip Code:54629-8253
Mailing Address - Country:US
Mailing Address - Phone:320-223-5767
Mailing Address - Fax:
Practice Address - Street 1:107 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:COCHRANE
Practice Address - State:WI
Practice Address - Zip Code:54622-7311
Practice Address - Country:US
Practice Address - Phone:507-730-1453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-13
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI253632-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse