Basic Information
| Provider Information | |||||||||
| NPI: | 1801159264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1821 S WEBSTER AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543012253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204964700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1821 S WEBSTER AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543012253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204964700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2012 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2012018501 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 01080544A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 036.150159 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | MD.207877 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 01080544A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 036.150159 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.