Provider Demographics
NPI:1871527341
Name:MICKE-KOPETSKY, JENNIFER R (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:MICKE-KOPETSKY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:R
Other - Last Name:MICKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:6425 W MEQUON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-1855
Practice Address - Country:US
Practice Address - Phone:262-242-0051
Practice Address - Fax:262-242-8927
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28560207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00854893OtherRR MEDICARE
WI31488700Medicaid
WI46236-0288Medicare PIN
WI01994-0288Medicare PIN
WI31488700Medicaid