Basic Information
| Provider Information | |||||||||
| NPI: | 1225697766 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BIRDSEY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | STOUGHTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535891801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088772777 | ||||||||
| FaxNumber: | 6088772774 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | STOUGHTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535891801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088772777 | ||||||||
| FaxNumber: | 6088772774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2019 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 4680-23 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 4680 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1225697766 | 05 | WI | MEDICAID |