Provider Demographics
NPI:1568907772
Name:JANSEN, CAROLYN (PT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:JANSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5300 MEMORIAL DR
Mailing Address - Street 2:AURORA REHABILITATION CENTER
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-3923
Mailing Address - Country:US
Mailing Address - Phone:920-312-1992
Mailing Address - Fax:
Practice Address - Street 1:5300 MEMORIAL DR
Practice Address - Street 2:AURORA REHABILITATION CENTER
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241
Practice Address - Country:US
Practice Address - Phone:920-312-1992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-23
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13571-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist