Provider Demographics
NPI:1194587352
Name:JAKU, JENNIFER ANN (RDH)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:JAKU
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:JAKUBICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 S TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-6922
Mailing Address - Country:US
Mailing Address - Phone:920-787-5514
Mailing Address - Fax:920-787-4737
Practice Address - Street 1:207 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2450
Practice Address - Country:US
Practice Address - Phone:920-356-5012
Practice Address - Fax:920-273-3169
Is Sole Proprietor?:No
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6215-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist