Provider Demographics
NPI:1568613461
Name:HERTEL, JANE MARIE (OTR)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:MARIE
Last Name:HERTEL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5798 S HWY T
Mailing Address - Street 2:
Mailing Address - City:DENMARK
Mailing Address - State:WI
Mailing Address - Zip Code:54208-9463
Mailing Address - Country:US
Mailing Address - Phone:920-863-6214
Mailing Address - Fax:
Practice Address - Street 1:5798 S HWY T
Practice Address - Street 2:
Practice Address - City:DENMARK
Practice Address - State:WI
Practice Address - Zip Code:54208
Practice Address - Country:US
Practice Address - Phone:920-863-6214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1568-026225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40529100Medicaid
WI1568-026OtherSTATE OF WISCONSIN DEPARTMENT OF REGULATION AND LICENSING