Provider Demographics
NPI:1083126874
Name:TADYCH, JENNA L (COTA)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:L
Last Name:TADYCH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2341 SKYLINE DR APT 2D
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-5491
Mailing Address - Country:US
Mailing Address - Phone:906-221-7161
Mailing Address - Fax:
Practice Address - Street 1:3129 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3062
Practice Address - Country:US
Practice Address - Phone:920-459-4382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5381-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant