Provider Demographics
NPI:1255465647
Name:WISKE, JAI L (PT)
Entity Type:Individual
Prefix:
First Name:JAI
Middle Name:L
Last Name:WISKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20827 N 27TH AVE
Mailing Address - Street 2:#324
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-3203
Mailing Address - Country:US
Mailing Address - Phone:808-755-5885
Mailing Address - Fax:
Practice Address - Street 1:17233 N HOLMES BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-2018
Practice Address - Country:US
Practice Address - Phone:602-547-1836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6367225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist