Provider Demographics
NPI:1629078217
Name:MARSHALL, JENNIFER M (PAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:LAUBENSTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1531 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915
Mailing Address - Country:US
Mailing Address - Phone:920-996-3700
Mailing Address - Fax:
Practice Address - Street 1:2105 E ENTERPRISE AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7862
Practice Address - Country:US
Practice Address - Phone:920-560-1000
Practice Address - Fax:920-731-6732
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI888363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42960000Medicaid
WI0575 45300Medicare PIN
WI0579 71018Medicare PIN
WI42960000Medicaid