Provider Demographics
NPI:1336496108
Name:VICKMAN, BRITTANY L (PT)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:L
Last Name:VICKMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:BRITTANY
Other - Middle Name:L
Other - Last Name:JAEGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 866308
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75086-6308
Mailing Address - Country:US
Mailing Address - Phone:972-596-2500
Mailing Address - Fax:267-321-2044
Practice Address - Street 1:3101 S PACKERLAND DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54956
Practice Address - Country:US
Practice Address - Phone:920-592-3845
Practice Address - Fax:920-592-3061
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12059-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1336496108Medicaid