Provider Demographics
NPI:1265469944
Name:KACZMAREK, JESSICA A (OTR)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:A
Last Name:KACZMAREK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:A
Other - Last Name:HERMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:855 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OCONTO FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54154-1241
Mailing Address - Country:US
Mailing Address - Phone:920-846-3444
Mailing Address - Fax:920-846-0250
Practice Address - Street 1:855 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-1241
Practice Address - Country:US
Practice Address - Phone:920-846-3444
Practice Address - Fax:920-846-0250
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3205026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40813000Medicaid
000183595Medicare ID - Type Unspecified