Provider Demographics
NPI:1740989045
Name:PENNA, JENNIFER NICOLE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:PENNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 CHAPEL HILL DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53038-9470
Mailing Address - Country:US
Mailing Address - Phone:920-390-0839
Mailing Address - Fax:
Practice Address - Street 1:224 CONNELLY DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549
Practice Address - Country:US
Practice Address - Phone:920-650-4414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI159229163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse