Provider Demographics
NPI:1467659367
Name:STRADER, JENNY (PT)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:STRADER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 TALON CT
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-6646
Mailing Address - Country:US
Mailing Address - Phone:260-615-3911
Mailing Address - Fax:
Practice Address - Street 1:5800 FAIRFIELD AVE STE 150
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-3450
Practice Address - Country:US
Practice Address - Phone:260-744-5585
Practice Address - Fax:260-744-5586
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14004225100000X
IN05009253A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN220680CMedicare PIN