Basic Information
| Provider Information | |||||||||
| NPI: | 1144955394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROCKWEILER | ||||||||
| FirstName: | JADE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLEMENT | ||||||||
| OtherFirstName: | JADE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | OTR | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2000 N DEWEY AVE | ||||||||
| Address2: | |||||||||
| City: | REEDSBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539591049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087686243 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2000 N DEWEY AVE | ||||||||
| Address2: | |||||||||
| City: | REEDSBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539591049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087686243 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2022 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 6566-26 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.