Basic Information
| Provider Information | |||||||||
| NPI: | 1962624700 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAPLEMAN | ||||||||
| FirstName: | JILLIAN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUGHES | ||||||||
| OtherFirstName: | JILLIAN | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 509 NEWMAN RD | ||||||||
| Address2: | |||||||||
| City: | RACINE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 534063448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627708355 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8633 32ND AVE | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531425187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626948300 | ||||||||
| FaxNumber: | 2626943622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225200000X | 680-019 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 40403800 | 05 | WI | MEDICAID |