Provider Demographics
NPI:1598954844
Name:REA, JESSI (ATC)
Entity Type:Individual
Prefix:
First Name:JESSI
Middle Name:
Last Name:REA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 N 75TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3515
Mailing Address - Country:US
Mailing Address - Phone:262-227-3473
Mailing Address - Fax:
Practice Address - Street 1:2835 N GRANDVIEW BLVD
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-5546
Practice Address - Country:US
Practice Address - Phone:262-574-1100
Practice Address - Fax:262-574-5193
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI662-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer