Provider Demographics
NPI:1487111324
Name:HASKINS, JENNELLE
Entity type:Individual
Prefix:
First Name:JENNELLE
Middle Name:
Last Name:HASKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNELLE
Other - Middle Name:
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:106 S HOLMEN DR STE 2
Mailing Address - Street 2:
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-9468
Mailing Address - Country:US
Mailing Address - Phone:608-526-9888
Mailing Address - Fax:
Practice Address - Street 1:106 S HOLMEN DR STE 2
Practice Address - Street 2:
Practice Address - City:HOLMEN
Practice Address - State:WI
Practice Address - Zip Code:54636-9468
Practice Address - Country:US
Practice Address - Phone:608-526-9888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14522-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist