Provider Demographics
NPI:1457324667
Name:EWER, JACKIE LOTTIE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:LOTTIE
Last Name:EWER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MISS
Other - First Name:JACKIE
Other - Middle Name:LOTTIE
Other - Last Name:ODACHOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:17280 W NORTH AVE
Mailing Address - Street 2:#104
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4366
Mailing Address - Country:US
Mailing Address - Phone:262-780-0707
Mailing Address - Fax:262-780-0717
Practice Address - Street 1:17280 W NORTH AVE
Practice Address - Street 2:#104
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4366
Practice Address - Country:US
Practice Address - Phone:262-780-0707
Practice Address - Fax:262-780-0717
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3081026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist