Provider Demographics
NPI:1033322847
Name:EVENSON, JANE
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:EVENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:
Other - Last Name:CHERTI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:N4864 N HELENVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HELENVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53137-9797
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1130 COLLINS RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-2939
Practice Address - Country:US
Practice Address - Phone:920-674-6077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI578-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant