Healthcare Provider Details

I. General information

NPI: 1295104305
Provider Name (Legal Business Name): JAKE E KENDALL APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E CAPITOL DR
APPLETON WI
54911-8735
US

IV. Provider business mailing address

122 E COLLEGE AVE
APPLETON WI
54911-5794
US

V. Phone/Fax

Practice location:
  • Phone: 920-830-6788
  • Fax: 999-999-9999
Mailing address:
  • Phone: 920-996-3264
  • Fax: 920-830-5970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19857
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7899
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: