Healthcare Provider Details

I. General information

NPI: 1558907840
Provider Name (Legal Business Name): KATHERINE JEFFERIES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W MAIN ST
WHITEWATER WI
53190-1790
US

IV. Provider business mailing address

949 PARKWOOD LN
JEFFERSON WI
53549-3003
US

V. Phone/Fax

Practice location:
  • Phone: 262-472-1300
  • Fax:
Mailing address:
  • Phone: 608-343-9343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1400X
TaxonomyCollege Health Registered Nurse
License Number173504
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: