Provider Demographics
NPI:1669782587
Name:ANDERSEN, JENNIFER JEAN (RN)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JEAN
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:MR
Other - First Name:GILLIAM
Other - Middle Name:RICHARDS
Other - Last Name:SANFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2027 WEST RIDGE DR.
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703
Mailing Address - Country:US
Mailing Address - Phone:715-271-3847
Mailing Address - Fax:
Practice Address - Street 1:2027 WEST RIDGE DR.
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703
Practice Address - Country:US
Practice Address - Phone:715-271-3847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI143283-30163W00000X
WI13210-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No183500000XPharmacy Service ProvidersPharmacist