MEDICARE: JEANNETTE PONDER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3140N1450X	Pediatric Skilled Nursing Facility	11818	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356303101
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEANNETTE PONDER

Provider Business Mailing Address
First Line	:	3152 N 24TH PL
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53206-1209
Country	:	US
Telephone Number	:	414-447-1489
Fax Number	:

Provider Business Practice Location Address
First Line	:	3152 N 24TH PL
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53206-1209
Country	:	US
Telephone Number	:	414-447-1489
Fax Number	:

Authorized Official
Title or Position	:	LPN RCS
Name	:	MS. JEANNETTE PONDER
Credential	:
Telephone Number	:	414-447-1489

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	08/22/2020

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