Provider Demographics
NPI:1356854376
Name:LOIS, JESSICA GAIL (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:GAIL
Last Name:LOIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830B E GENEVA ST
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53115-1932
Mailing Address - Country:US
Mailing Address - Phone:262-728-9164
Mailing Address - Fax:262-728-9172
Practice Address - Street 1:830B E GENEVA ST
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-1932
Practice Address - Country:US
Practice Address - Phone:262-728-9164
Practice Address - Fax:262-728-9172
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2672-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant