Healthcare Provider Details

I. General information

NPI: 1891627980
Provider Name (Legal Business Name): JESSICA NELSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 LAKE ST
PEWAUKEE WI
53072-3630
US

IV. Provider business mailing address

N88W18561 DUKE ST
MENOMONEE FALLS WI
53051-1905
US

V. Phone/Fax

Practice location:
  • Phone: 262-701-5532
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number222727-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: