Healthcare Provider Details

I. General information

NPI: 1760115547
Provider Name (Legal Business Name): JESSI GUDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2022
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N20W22961 WATERTOWN RD
WAUKESHA WI
53186-1306
US

IV. Provider business mailing address

N20W22961 WATERTOWN RD
WAUKESHA WI
53186-1306
US

V. Phone/Fax

Practice location:
  • Phone: 262-875-5070
  • Fax:
Mailing address:
  • Phone: 262-875-5070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7787-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: