Provider Demographics
NPI:1669742805
Name:POLICH, JENNIFER JO (RDH)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:JO
Last Name:POLICH
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:JO
Other - Last Name:JOHANNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:225 OSTERMANN DRIVE
Mailing Address - Street 2:CESA #11 RURAL HEALTH DENTAL CLINIC
Mailing Address - City:TURTLE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54889
Mailing Address - Country:US
Mailing Address - Phone:715-986-2020
Mailing Address - Fax:715-986-2041
Practice Address - Street 1:225 OSTERMANN DRIVE
Practice Address - Street 2:CESA #11 RURAL HEALTH DENTAL CLINIC
Practice Address - City:TURTLE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54889
Practice Address - Country:US
Practice Address - Phone:715-986-2020
Practice Address - Fax:715-986-2041
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5572-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist