Provider Demographics
NPI:1548406416
Name:BRANDT, JESSICA MARIE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:MARIE
Last Name:BRANDT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:KEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:N3134 PARKWAY RD
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-9117
Mailing Address - Country:US
Mailing Address - Phone:715-610-8154
Mailing Address - Fax:
Practice Address - Street 1:110 E 5TH AVE
Practice Address - Street 2:DEPARTMENT OF PHYSICAL THERAPY
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2710
Practice Address - Country:US
Practice Address - Phone:715-623-9449
Practice Address - Fax:715-623-9425
Is Sole Proprietor?:No
Enumeration Date:2008-12-26
Last Update Date:2008-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11077-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist