Provider Demographics
NPI:1558605899
Name:OOSTDYK, JILL (PTA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:OOSTDYK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MILL ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:WI
Mailing Address - Zip Code:54642-8256
Mailing Address - Country:US
Mailing Address - Phone:715-416-3015
Mailing Address - Fax:
Practice Address - Street 1:400 COUNTY ROAD R
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-5129
Practice Address - Country:US
Practice Address - Phone:715-284-5396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1700-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant