Provider Demographics
NPI:1407906936
Name:JANKE, MICHELLE LEE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEE
Last Name:JANKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:LEE
Other - Last Name:JURENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3211 MEDITERRANEAN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53090-8426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5505 HIGHWAY Z
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9224
Practice Address - Country:US
Practice Address - Phone:262-306-2691
Practice Address - Fax:262-306-2689
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3940-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20125800Medicaid