Provider Demographics
NPI:1427224047
Name:DELFORGE, JEAN SOPHIE (PT)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:SOPHIE
Last Name:DELFORGE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SOPHIE
Other - Middle Name:JEAN
Other - Last Name:DELFORGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:3009 N RIVER RD
Mailing Address - Street 2:
Mailing Address - City:OCONTO
Mailing Address - State:WI
Mailing Address - Zip Code:54153-9435
Mailing Address - Country:US
Mailing Address - Phone:920-834-5893
Mailing Address - Fax:920-834-5893
Practice Address - Street 1:400 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-1764
Practice Address - Country:US
Practice Address - Phone:920-834-7808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-04
Last Update Date:2008-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1258-024225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics