Provider Demographics
NPI:1336663756
Name:MIELKE, JENNA R (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:R
Last Name:MIELKE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:R
Other - Last Name:PITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:416 E VERONA AVE
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-1227
Mailing Address - Country:US
Mailing Address - Phone:608-848-6628
Mailing Address - Fax:608-848-6629
Practice Address - Street 1:416 E VERONA AVE
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-1227
Practice Address - Country:US
Practice Address - Phone:608-848-6628
Practice Address - Fax:608-848-6629
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13930-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist