Healthcare Provider Details

I. General information

NPI: 1518222777
Provider Name (Legal Business Name): JESSICA ELENA KIRKWOOD WEAVER CPM, LM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 07/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N9215 130TH ST
DOWNING WI
54734-9480
US

IV. Provider business mailing address

PO BOX 222
BOYCEVILLE WI
54725-0222
US

V. Phone/Fax

Practice location:
  • Phone: 715-308-9540
  • Fax:
Mailing address:
  • Phone: 715-308-9540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number129-49
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: