Provider Demographics
NPI:1114415320
Name:BRONKEMA, JESSICA L (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:BRONKEMA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11080 PINE VIEW LN
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-9596
Mailing Address - Country:US
Mailing Address - Phone:734-856-8199
Mailing Address - Fax:
Practice Address - Street 1:11080 PINE VIEW LN
Practice Address - Street 2:
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182-9596
Practice Address - Country:US
Practice Address - Phone:734-856-8199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist