Provider Demographics
NPI:1487867412
Name:WITCZAK, JENNIFER M (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:WITCZAK
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 1:3602 S LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207
Mailing Address - Country:US
Mailing Address - Phone:414-517-0893
Mailing Address - Fax:
Practice Address - Street 1:1301 W CANAL ST STE 200
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2667
Practice Address - Country:US
Practice Address - Phone:844-708-4819
Practice Address - Fax:414-645-8811
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5910-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist