Provider Demographics
NPI:1023457918
Name:KOOSMANN, JERELYN MARY (RDH)
Entity type:Individual
Prefix:MRS
First Name:JERELYN
Middle Name:MARY
Last Name:KOOSMANN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:JERELYN
Other - Middle Name:MARY
Other - Last Name:STENCIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:53585 NOKOMIS RD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-4272
Mailing Address - Country:US
Mailing Address - Phone:715-685-7887
Mailing Address - Fax:715-685-7857
Practice Address - Street 1:53585 NOKOMIS RD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-4272
Practice Address - Country:US
Practice Address - Phone:715-685-7887
Practice Address - Fax:715-685-7857
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5103-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist