Basic Information
| Provider Information | |||||||||
| NPI: | 1972042315 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NELSON | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | CHRISTINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | HEMATOLOGY AND ONCOLOGY | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148054600 | ||||||||
| FaxNumber: | 4148056805 | ||||||||
| Practice Location | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | HEMATOLOGY AND ONCOLOGY | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148054600 | ||||||||
| FaxNumber: | 4148056805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2017 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 7360-33 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 7360-33 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2100X | 7360-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 1972042315 | 05 | WI | MEDICAID |