Provider Demographics
NPI:1457877284
Name:WACHHOLZ, JENNIFER L (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:WACHHOLZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 S STOUGHTON RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-2257
Mailing Address - Country:US
Mailing Address - Phone:608-260-6000
Mailing Address - Fax:608-260-6366
Practice Address - Street 1:1821 S STOUGHTON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-2257
Practice Address - Country:US
Practice Address - Phone:608-260-6000
Practice Address - Fax:608-260-6366
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4128363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1457877284Medicaid