Provider Demographics
NPI:1356641633
Name:STORY, JARED
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:STORY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9047 W GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-2808
Mailing Address - Country:US
Mailing Address - Phone:414-453-9290
Mailing Address - Fax:414-607-0924
Practice Address - Street 1:9047 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-2808
Practice Address - Country:US
Practice Address - Phone:414-453-9290
Practice Address - Fax:414-607-0924
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1679-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1356641633Medicaid