Healthcare Provider Details

I. General information

NPI: 1467531848
Provider Name (Legal Business Name): JESSICA CATHERINE PHELPS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2006
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE PEDIATRIC PSYCHIATRY
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVE PEDIATRIC PSYCHIATRY
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-2932
  • Fax: 414-266-3735
Mailing address:
  • Phone: 414-266-2932
  • Fax: 414-266-3735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number51641
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number5164120
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: