Basic Information
| Provider Information | |||||||||
| NPI: | 1780965657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHUTTA | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | E | ||||||||
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| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VANDERBOOM | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10625 W NORTH AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532262315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148775350 | ||||||||
| FaxNumber: | 4148775360 | ||||||||
| Practice Location | |||||||||
| Address1: | 3237 S 16TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532154526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146475000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2011 | ||||||||
| LastUpdateDate: | 09/07/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4515-033 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 4515-033 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.