Basic Information
| Provider Information | |||||||||
| NPI: | 1295104305 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENDALL | ||||||||
| FirstName: | JAKE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 E COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549115794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209963264 | ||||||||
| FaxNumber: | 9208305970 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 E CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549118735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208306788 | ||||||||
| FaxNumber: | 9999999999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 19857 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 7899 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.