Healthcare Provider Details

I. General information

NPI: 1013556984
Provider Name (Legal Business Name): JENNIFER MARIE KETTERHAGEN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER MARIE FLEEGE PHARMD

II. Dates (important events)

Enumeration Date: 12/24/2019
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 2ND ST
NEENAH WI
54956-2883
US

IV. Provider business mailing address

N2472 SALLY CT
GREENVILLE WI
54942-9732
US

V. Phone/Fax

Practice location:
  • Phone: 920-454-5080
  • Fax:
Mailing address:
  • Phone: 563-513-1079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number20163-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: