Basic Information
| Provider Information | |||||||||
| NPI: | 1770098352 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | JENNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1051 CLARK ST | ||||||||
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| City: | REEDSBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539592321 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1051 CLARK ST | ||||||||
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| City: | REEDSBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539592321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6085247500 | ||||||||
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| ProviderEnumerationDate: | 12/05/2017 | ||||||||
| LastUpdateDate: | 12/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 5468-27 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.