Basic Information
| Provider Information | |||||||||
| NPI: | 1336663756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIELKE | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | PITT | ||||||||
| OtherFirstName: | JENNA | ||||||||
| OtherMiddleName: | R | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 416 E VERONA AVE | ||||||||
| Address2: | |||||||||
| City: | VERONA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535931227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088486628 | ||||||||
| FaxNumber: | 6088486629 | ||||||||
| Practice Location | |||||||||
| Address1: | 416 E VERONA AVE | ||||||||
| Address2: | |||||||||
| City: | VERONA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535931227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088486628 | ||||||||
| FaxNumber: | 6088486629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2017 | ||||||||
| LastUpdateDate: | 03/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 13930-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.