1063589505 NPI number — DR. JESSICA L SERWE DC

Table of content: DR. JESSICA L SERWE DC (NPI 1063589505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063589505 NPI number — DR. JESSICA L SERWE DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SERWE
Provider First Name:
JESSICA
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RODRIGUEZ
Provider Other First Name:
JESSICA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063589505
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
976 E JOHNSON ST
Provider Second Line Business Mailing Address:
SUITE 900
Provider Business Mailing Address City Name:
FOND DU LAC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54935-9746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-907-1700
Provider Business Mailing Address Fax Number:
920-907-1708

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
976 E JOHNSON ST
Provider Second Line Business Practice Location Address:
SUITE 900
Provider Business Practice Location Address City Name:
FOND DU LAC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54935-9746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-907-1700
Provider Business Practice Location Address Fax Number:
920-907-1708
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4174-012 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 38185900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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