Provider Demographics
NPI:1063767226
Name:BAHR, JESSICA N (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:N
Last Name:BAHR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:N
Other - Last Name:GRANDLICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:7001 S HOWELL AVE
Practice Address - Street 2:SUITE 900
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-1407
Practice Address - Country:US
Practice Address - Phone:262-898-4400
Practice Address - Fax:414-435-3406
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2985-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2985-23OtherLICENSE