Provider Demographics
NPI:1508264607
Name:STOTZ, JESSICA MAE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MAE
Last Name:STOTZ
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:3362 140TH ST
Mailing Address - City:FREDERIC
Mailing Address - State:WI
Mailing Address - Zip Code:54837-0246
Mailing Address - Country:US
Mailing Address - Phone:715-220-9696
Mailing Address - Fax:
Practice Address - Street 1:5000 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-3900
Practice Address - Country:US
Practice Address - Phone:715-220-9696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12933-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist