Basic Information
| Provider Information | |||||||||
| NPI: | 1174627400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOBERG | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | CPNP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WITT | ||||||||
| OtherFirstName: | JESSICA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3630 N HICKORY LANE | ||||||||
| Address2: | |||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626461338 | ||||||||
| FaxNumber: | 2626467067 | ||||||||
| Practice Location | |||||||||
| Address1: | 11101 W LINCOLN AVE | ||||||||
| Address2: | ROGERS MEMORIAL HOSPITAL | ||||||||
| City: | WEST ALLIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143273000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2006 | ||||||||
| LastUpdateDate: | 10/13/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 246333 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 41195500 | 05 | WI | MEDICAID |