Provider Demographics
NPI:1255326831
Name:BROVOLD, JESSIE RAE (ATC, ATR)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:RAE
Last Name:BROVOLD
Suffix:
Gender:F
Credentials:ATC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 DELAFIELD ST
Mailing Address - Street 2:120
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3417
Mailing Address - Country:US
Mailing Address - Phone:262-544-5311
Mailing Address - Fax:
Practice Address - Street 1:1111 DELAFIELD ST
Practice Address - Street 2:120
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3417
Practice Address - Country:US
Practice Address - Phone:262-544-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2013-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI655-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer