Provider Demographics
NPI:1508887464
Name:OPTIMAL PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:OPTIMAL PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:JESCHKE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:920-648-2400
Mailing Address - Street 1:805 ELM ST
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-1127
Mailing Address - Country:US
Mailing Address - Phone:920-648-2400
Mailing Address - Fax:920-648-2444
Practice Address - Street 1:805 ELM ST
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-1127
Practice Address - Country:US
Practice Address - Phone:920-648-2400
Practice Address - Fax:920-648-2444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40431100Medicaid
WI000083028Medicare ID - Type UnspecifiedMEDICARE GROUP ID