Provider Demographics
NPI:1679558878
Name:MCHENRY, JEAN M (NP)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:MCHENRY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:M
Other - Last Name:O'CONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:3263 EATON ROAD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311
Mailing Address - Country:US
Mailing Address - Phone:920-433-3456
Mailing Address - Fax:
Practice Address - Street 1:3263 EATON ROAD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311
Practice Address - Country:US
Practice Address - Phone:920-433-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1766363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1766-033OtherLICENSE
WIWI1097004Medicare Oscar/Certification
WIWI1119009Medicare Oscar/Certification
WI073550054Medicare Oscar/Certification
WI000004Medicare Oscar/Certification
WIP18963Medicare UPIN
WI1766-033OtherLICENSE