Provider Demographics
NPI:1497780472
Name:BROCKMAN, JAN M (PT)
Entity Type:Individual
Prefix:MRS
First Name:JAN
Middle Name:M
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:JAN
Other - Middle Name:M
Other - Last Name:STUTTGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 276
Mailing Address - Street 2:
Mailing Address - City:PITTSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54466-0276
Mailing Address - Country:US
Mailing Address - Phone:715-884-2333
Mailing Address - Fax:715-884-2333
Practice Address - Street 1:5308 2ND AVE
Practice Address - Street 2:
Practice Address - City:PITTSVILLE
Practice Address - State:WI
Practice Address - Zip Code:54466
Practice Address - Country:US
Practice Address - Phone:715-884-2333
Practice Address - Fax:715-884-2333
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4058-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIPENDINGMedicare ID - Type Unspecified