Healthcare Provider Details

I. General information

NPI: 1568607141
Provider Name (Legal Business Name): JILL RENEA JAHNKE R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL RENEA SHANNON R.N.

II. Dates (important events)

Enumeration Date: 12/10/2008
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 LAKEVIEW DRIVE
SUAMICO WI
54143-8318
US

IV. Provider business mailing address

4141 LAKEVIEW DR
SUAMICO WI
54173-8318
US

V. Phone/Fax

Practice location:
  • Phone: 920-427-6055
  • Fax:
Mailing address:
  • Phone: 920-427-6055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number128988-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: