Provider Demographics
NPI:1427303585
Name:MCNULTY, JESSICA LOREN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LOREN
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:LOREN
Other - Last Name:DONOFRIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:250 E. ERIE ST.
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686
Mailing Address - Country:US
Mailing Address - Phone:708-369-9781
Mailing Address - Fax:414-266-2635
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC EMERGENCY MEDICINE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-2625
Practice Address - Fax:414-266-2635
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2993363A00000X
IL085005379363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant