Provider Demographics
NPI:1346352440
Name:WITTY, JODI ROANA (PT)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:ROANA
Last Name:WITTY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 N MAYFAIR RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1403
Mailing Address - Country:US
Mailing Address - Phone:414-476-8183
Mailing Address - Fax:414-476-8465
Practice Address - Street 1:2525 N MAYFAIR RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1403
Practice Address - Country:US
Practice Address - Phone:414-476-8183
Practice Address - Fax:414-476-8465
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3758-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21280000Medicaid
WI40451100Medicaid