Healthcare Provider Details

I. General information

NPI: 1922573773
Provider Name (Legal Business Name): JESSICA KUPSER BSN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 BLACK EARTH RD
WALES WI
53183-9759
US

IV. Provider business mailing address

530 WINDSTONE DR UNIT 201
HARTLAND WI
53029-1658
US

V. Phone/Fax

Practice location:
  • Phone: 414-630-8104
  • Fax:
Mailing address:
  • Phone: 414-630-8104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number143519-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: