Provider Demographics
NPI:1376956367
Name:GATES, JENNIFER MICHELE
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MICHELE
Last Name:GATES
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:MICHELE
Other - Last Name:KRUEGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W2093 GARY LN
Mailing Address - Street 2:
Mailing Address - City:IXONIA
Mailing Address - State:WI
Mailing Address - Zip Code:53036-9724
Mailing Address - Country:US
Mailing Address - Phone:920-253-5625
Mailing Address - Fax:
Practice Address - Street 1:W2093 GARY LN
Practice Address - Street 2:
Practice Address - City:IXONIA
Practice Address - State:WI
Practice Address - Zip Code:53036-9724
Practice Address - Country:US
Practice Address - Phone:920-253-5625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI318264-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse