Provider Demographics
NPI:1003797499
Name:MADDOCK, JESSIE LAUREN
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:LAUREN
Last Name:MADDOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5521 BOX ELDER RD
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:WI
Mailing Address - Zip Code:53559-9769
Mailing Address - Country:US
Mailing Address - Phone:847-436-9088
Mailing Address - Fax:
Practice Address - Street 1:5521 BOX ELDER RD
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:WI
Practice Address - Zip Code:53559-9769
Practice Address - Country:US
Practice Address - Phone:847-436-9088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-11
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI612-49176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife