Healthcare Provider Details

I. General information

NPI: 1033162078
Provider Name (Legal Business Name): JENNIFER ANNE LUEDKE PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER ANNE MIRENDA PAC

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N 99TH ST SUITE 101
WAUWATOSA WI
53226-4339
US

IV. Provider business mailing address

601 N 99TH ST SUITE 101
WAUWATOSA WI
53226-4339
US

V. Phone/Fax

Practice location:
  • Phone: 414-988-5100
  • Fax: 414-988-5102
Mailing address:
  • Phone: 414-988-5100
  • Fax: 414-988-5102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: