Provider Demographics
NPI:1508970286
Name:THEOBALD, JANE CADE (PT)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:CADE
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:JANE
Other - Middle Name:ELLEN
Other - Last Name:THEOBALD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:10908 WINDHAVEN CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-3103
Mailing Address - Country:US
Mailing Address - Phone:513-793-9573
Mailing Address - Fax:
Practice Address - Street 1:10567 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-4451
Practice Address - Country:US
Practice Address - Phone:513-793-5525
Practice Address - Fax:513-984-5758
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-01082225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2454026Medicaid
OH2454026Medicaid