Provider Demographics
NPI:1427221779
Name:POE, JODIE LEE (PT)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:LEE
Last Name:POE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JODIE
Other - Middle Name:LEE
Other - Last Name:MUELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:990 JANESVILLE ST
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-2954
Mailing Address - Country:US
Mailing Address - Phone:608-835-5373
Mailing Address - Fax:608-835-0373
Practice Address - Street 1:990 JANESVILLE ST
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575-2954
Practice Address - Country:US
Practice Address - Phone:608-835-5373
Practice Address - Fax:608-835-0373
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3472-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36119800Medicaid