Healthcare Provider Details

I. General information

NPI: 1417203910
Provider Name (Legal Business Name): CASSANDRA LEE JENKINS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W GREEN TREE RD #301
GLENDALE WI
53209-2955
US

IV. Provider business mailing address

1600 W GREEN TREE RD #301
GLENDALE WI
53209-2955
US

V. Phone/Fax

Practice location:
  • Phone: 414-446-5895
  • Fax:
Mailing address:
  • Phone: 414-446-5895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number86722-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: