Provider Demographics
NPI:1376592634
Name:KING, JENNIFER J (OTR)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:KING
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2013 CARDINAL WAY
Mailing Address - Street 2:
Mailing Address - City:WAUNAKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53597
Mailing Address - Country:US
Mailing Address - Phone:608-850-9073
Mailing Address - Fax:
Practice Address - Street 1:14 ELLIS POTTER CT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-2478
Practice Address - Country:US
Practice Address - Phone:608-234-5990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4060026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40861300Medicaid