Healthcare Provider Details

I. General information

NPI: 1316049943
Provider Name (Legal Business Name): JENNIFER ANN LENIUS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 E MASON ST
GREEN BAY WI
54302-3759
US

IV. Provider business mailing address

2430 E MASON ST
GREEN BAY WI
54302-3759
US

V. Phone/Fax

Practice location:
  • Phone: 920-406-9863
  • Fax:
Mailing address:
  • Phone: 920-406-9863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2006
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2006
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: