Healthcare Provider Details

I. General information

NPI: 1578732897
Provider Name (Legal Business Name): JENNIFER JURY MCINTOSH D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER LYN JURY D.O.

II. Dates (important events)

Enumeration Date: 02/21/2008
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE DEPT OF OBSTETRICS AND GYNECOLOGY
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE DEPT OF OBSTETRICS AND GYNECOLOGY
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-6624
  • Fax: 414-805-6622
Mailing address:
  • Phone: 414-805-6624
  • Fax: 414-805-6622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number63633
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number5018
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number63633
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number11013849A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: