Healthcare Provider Details

I. General information

NPI: 1972750578
Provider Name (Legal Business Name): JENNIFER L KILLEEN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3727 W WISCONSIN AVE
MILWAUKEE WI
53208-3182
US

IV. Provider business mailing address

3727 W WISCONSIN AVE
MILWAUKEE WI
53208-3182
US

V. Phone/Fax

Practice location:
  • Phone: 414-291-2626
  • Fax: 414-431-0050
Mailing address:
  • Phone: 414-291-2626
  • Fax: 414-431-0050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number146124-030
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number148825-32
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: