Provider Demographics
NPI:1699295626
Name:PROVANCE, JENNA K (PA-C)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:K
Last Name:PROVANCE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:K
Other - Last Name:HOROMANSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2414 W KOHLER MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081
Mailing Address - Country:US
Mailing Address - Phone:920-457-4461
Mailing Address - Fax:920-459-1483
Practice Address - Street 1:2414 KOHLER MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3129
Practice Address - Country:US
Practice Address - Phone:920-457-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4027-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1699295626Medicaid
WIK400398570OtherMEDICARE