Healthcare Provider Details

I. General information

NPI: 1548223746
Provider Name (Legal Business Name): HEIDI J JENNRICH APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MCMILLEN STREET
FORT ATKINSON WI
53538-1223
US

IV. Provider business mailing address

500 MCMILLEN STREET
FORT ATKINSON WI
53538-1223
US

V. Phone/Fax

Practice location:
  • Phone: 950-563-5571
  • Fax: 920-563-7705
Mailing address:
  • Phone: 950-563-5571
  • Fax: 920-563-7705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2334-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: