Provider Demographics
NPI:1194956417
Name:HAGEN, JESSICA DAWN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:DAWN
Last Name:HAGEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:DAWN
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5330 W. VILLARD AVENUE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218
Mailing Address - Country:US
Mailing Address - Phone:414-463-9159
Mailing Address - Fax:414-831-0422
Practice Address - Street 1:5330 W. VILLARD AVENUE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218
Practice Address - Country:US
Practice Address - Phone:414-463-9159
Practice Address - Fax:414-831-0422
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2478-023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical