Provider Demographics
NPI:1447280714
Name:GRASSE, JESSIE M (NP)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:M
Last Name:GRASSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:M
Other - Last Name:COONEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:122 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5794
Mailing Address - Country:US
Mailing Address - Phone:920-996-3264
Mailing Address - Fax:920-830-5970
Practice Address - Street 1:4480 W SPENCER ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-9106
Practice Address - Country:US
Practice Address - Phone:920-738-4800
Practice Address - Fax:920-738-5749
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2336363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43999800Medicaid
WI43999800Medicaid