Basic Information
| Provider Information | |||||||||
| NPI: | 1992238927 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LICHMAN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PTA | ||||||||
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| OtherLastName: | SAMUELSON | ||||||||
| OtherFirstName: | JESSICA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 519 NORTH DALLAS ST | ||||||||
| Address2: | |||||||||
| City: | RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628730590 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2650 65TH AVE | ||||||||
| Address2: | |||||||||
| City: | OSCEOLA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152941100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2017 | ||||||||
| LastUpdateDate: | 04/06/2017 | ||||||||
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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 | 1944-19 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.