Provider Demographics
NPI:1578205399
Name:HUTCHERSON, JEOFFREY ROMANE (MT)
Entity Type:Individual
Prefix:
First Name:JEOFFREY
Middle Name:ROMANE
Last Name:HUTCHERSON
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 S WATERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-9259
Mailing Address - Country:US
Mailing Address - Phone:262-894-3515
Mailing Address - Fax:
Practice Address - Street 1:409 SONYA DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3035
Practice Address - Country:US
Practice Address - Phone:262-894-3515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1113-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist