Healthcare Provider Details

I. General information

NPI: 1578452249
Provider Name (Legal Business Name): JESSICA LYN HERMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 S MONROE AVE
GREEN BAY WI
54301-4054
US

IV. Provider business mailing address

424 S MONROE AVE
GREEN BAY WI
54301-4054
US

V. Phone/Fax

Practice location:
  • Phone: 920-437-7206
  • Fax:
Mailing address:
  • Phone: 920-437-7206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number7001717-16
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: