Provider Demographics
NPI:1013553031
Name:SOBOLESKI, JENNA LYNN
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:LYNN
Last Name:SOBOLESKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W1601 STATE ROAD 49
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53006-1436
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 E SOUTH RIVER ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-2223
Practice Address - Country:US
Practice Address - Phone:920-997-8828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6615-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist