Healthcare Provider Details

I. General information

NPI: 1528421013
Provider Name (Legal Business Name): JESSICA DE VALK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7322 W RAWSON AVE
FRANKLIN WI
53132-8117
US

IV. Provider business mailing address

9000 W WISCONSIN AVE # MS 958
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-433-9010
  • Fax: 414-433-9007
Mailing address:
  • Phone: 414-266-7615
  • Fax: 414-266-6238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number68053-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: