Healthcare Provider Details

I. General information

NPI: 1497575260
Provider Name (Legal Business Name): JEREMIAH ENNEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 HONEYSUCKLE LN
NEENAH WI
54956-3930
US

IV. Provider business mailing address

PO BOX 860912
MINNEAPOLIS MN
55486-0912
US

V. Phone/Fax

Practice location:
  • Phone: 507-514-2056
  • Fax:
Mailing address:
  • Phone: 715-838-5222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1104464
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number1104464
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: