Provider Demographics
NPI:1548527740
Name:GARDNER, JENNIFER L (LPN)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:L
Last Name:GARDNER
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 1:713 MATHER ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3559
Mailing Address - Country:US
Mailing Address - Phone:920-309-1486
Mailing Address - Fax:
Practice Address - Street 1:713 MATHER ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3559
Practice Address - Country:US
Practice Address - Phone:920-309-1486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI291818374U00000X, 376K00000X
WI312658-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide