=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154594208
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER REAGAN FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2008
-----------------------------------------------------
Last Update Date | 09/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5800 W LAYTON AVE
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53220-4021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-532-3067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15995 CORNELL CT
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53005-3253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-248-8666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 5448-33
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------