Provider Demographics
NPI:1427122902
Name:JENNERJOHN, MELISSA E (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:E
Last Name:JENNERJOHN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:E
Other - Last Name:SCHWEITZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1821 S STOUGHTON RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-2257
Mailing Address - Country:US
Mailing Address - Phone:608-260-6000
Mailing Address - Fax:608-260-6484
Practice Address - Street 1:1821 S STOUGHTON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-2257
Practice Address - Country:US
Practice Address - Phone:608-260-6000
Practice Address - Fax:608-260-6484
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2077-23363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1427122902Medicaid
WI61104OtherDEAN HEALTH INSUANCE