Provider Demographics
NPI:1346415007
Name:DAHLSTROM, JEAN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:DAHLSTROM
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 S ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3402
Mailing Address - Country:US
Mailing Address - Phone:920-445-7217
Mailing Address - Fax:920-445-7229
Practice Address - Street 1:617 S ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3402
Practice Address - Country:US
Practice Address - Phone:920-445-7217
Practice Address - Fax:920-445-7229
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1451024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40186400Medicaid