Healthcare Provider Details

I. General information

NPI: 1669909412
Provider Name (Legal Business Name): JESSICA MUTSCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5228 W FOND DU LAC AVE
MILWAUKEE WI
53216-1346
US

IV. Provider business mailing address

1327 E COLORADO ST APT 7
MILWAUKEE WI
53207-2268
US

V. Phone/Fax

Practice location:
  • Phone: 414-871-9111
  • Fax:
Mailing address:
  • Phone: 262-470-6738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: