Provider Demographics
NPI:1902102916
Name:FICKBOHM, JENNA SUE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:SUE
Last Name:FICKBOHM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13483 COUNTY ROAD F
Mailing Address - Street 2:
Mailing Address - City:GRANTSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54840-7363
Mailing Address - Country:US
Mailing Address - Phone:651-353-5535
Mailing Address - Fax:
Practice Address - Street 1:13483 COUNTY ROAD F
Practice Address - Street 2:
Practice Address - City:GRANTSBURG
Practice Address - State:WI
Practice Address - Zip Code:54840-7363
Practice Address - Country:US
Practice Address - Phone:651-353-5535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL068049-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse